BOOKS 


CHARLES  L  SCUDDER,  M.D. 


The  Treatment  of  Fractures 

Octavo  of  708  pages,  with  994  illustra- 
tions. Cloth,  $6.00  net ;  Half  Morocco, 
$7.50  net.  Seventh  Edition. 


Tumors  of  the  Jaws 

Octavo   of   391   pages,  with  353    illus- 
trations. Just  Ready. 


PLATE  I 


Case  of  osteo-chondro-myxo-sarcoma  before  operation  (Mixter). 


TUMORS  OF  THE  TAWS 

1844 


CHARLES    LOCKE    SCUDDER,  M.  D.' 

SURGEON   TO   THE    MASSACHUSETTS   GENERAL   HOSPITAL;     LECTURER  ON  SURGERY  IN  THE 
HARVARD    MEDICAL   SCHOOL;     FELLOW  OF   THE   AMERICAN   SURGICAL   ASSOCIA- 
TION;    MEMBER   OF   THE   SOCIETY   OF   CLINICAL    SURGERY 


With  jjj  Illustrations )  6  in  Colors 


PHILADELPHIA    AND    LONDON 

W.   B.  SAUNDERS   COMPANY 

ig  t  2 


COPYRIGHT,  1912,  BY  W.  B.  SAUNDERS  COMPANY 


PRINTED    IN    AMERICA 


TO 
JOHN  COLLINS  WARREN 


624401 


PREFACE 


NEW-GROWTHS  of  the  jaws  are  uncommon.  Certainly 
no  one  physician  meets  many  cases.  The  infrequ^ncy  of 
these  cases  increases  the  responsibility  of  the  practitioner. 
It  is  important  that  he  inform  himself  of  these  tumors. 

My  object  in  this  monograph  is,  first  of  all,  to  assist  the 
physician  in  determining  in  a  given  case  what  form  of  new- 
growth  is  present  and  what  is  its  best  treatment.  The 
second  aim  of  this  monograph  is  to  make  vivid  the  picture 
of  each  tumor  of  the  jaw  by  statistical  story  and  by  case- 
history,  so  that  the  physician  may  recognize  the  new- 
growths  of  the  jaws  in  their  early  stages. 

In  American  medical  literature  no  complete  description  of 
the  growths  of  the  jaws  exists. 

Christopher  Heath's  book  upon  "  Injuries  and  Diseases 
of  the  Jaws"*  illustrates  the  case  method  of  teaching  an 
unfamiliar  subject.  It  is  a  valuable  contribution. 

Perthes,  of  the  University  of  Leipzig,  in  a  monograph 
published  as  a  volume  of  the  Deutsche  Chirurgie  in  1907, 
has  contributed  to  German  medical  literature  the  best  upon 
this  important  subject.  The  bibliography  of  Perthes  is 
valuable  and  is  complete. 

Bloodgood,  of  Johns  Hopkins  University,  has  contributed 
the  most  satisfactory  articles  in  America  upon  new-growths 

*  J.  and  A.  Churchill,  1894 
11 


12  PREFACE 

of  the  jaws.     He  has  paid  especial  attention  to  the  pathology 
of  these  diseases. 

The  early  recognition,  by  the  physician,  of  new-growths 
of  the  jaws  is  the  first  step  toward  their  effective  treat- 
ment. 

It  is  true  of  jaw  growths,  as  of  gastric  diseases,  that 
terminal  conditions  of  malignancy  are  easy  to  recognize- 
early  malignant  diseases  are  difficult  to  diagnosticate.  The 
terminal  conditions  of  cancer  and  sarcoma  have  a  high 
operative  mortality;  early  malignant  disease  has  a  low 
operative  mortality.  Sarcoma  and  carcinoma  of  the 
jaws  are  curable  if  recognized  and  treated  early,  but  they  are 
most  malignant  and  incurable  if  operative  treatment  is 
delayed. 

The  greatest  effort  is  now  being  made  by  laboratory  in- 
vestigations to  discover  the  cause  of  malignant  disease 
(carcinoma,  sarcoma).  While  this  effort  is  being  made,  and 
until  it  is  crowned  by  success,  the  surgeon  must  continue 
his  attacks,  through  operative  measures,  upon  malignant 
disease  of  the  jaws.  It  behooves  him  to  discover  the  new- 
growth  in  its  initial  stages  if  he  would  rid  the  individual  of 
all  traces  of  its  presence. 

The  relative  malignancy  of  tumors  of  the  jaws  should 
be  more  generally  recognized. 

Operation  should  depend  largely  upon  the  character  of 
the  tumor.  A  mutilating  operation  should  not  be  done  for 
a  relatively  benign  form  of  malignant  growth.  On  the  other 
hand,  a  very  thorough  and  much  more  extensive  operation 
is  demanded  for  the  malignant  growths  than  has  been  prac- 
tised in  the  past.  The  surgeon  should  study  to  cure  each 
case  of  jaw  tumor  with  the  least  mutilation  possible. 


PREFACE  13 

There  are  certain  cases  of  malignant  disease  of  the  jaw 
in  which  a  complete  operation  will  actually  do  harm.  These 
cases  must  be  carefully  selected  and  treated  as  may  be 
most  helpful,  by  partial  operation,  by  x-ray  exposure,  by 
serums. 

In  cases  of  malignant  tumor  of  the  jaw  I  believe  that 
American  surgery  has  been  too  readily  satisfied  with  getting 
the  patient  off  the  operating  table  alive,  and  less  content 
to  undertake,  excepting  in  a  few  instances,  the  most  radical 
operation. 

In  advanced  cases  of  malignant  disease  of  the  jaws 
suitable  for  operative  treatment  a  large  percentage  of  cures 
is  necessarily  associated  with  a  great  immediate  mortality. 
Operative  technic  has  very  greatly  diminished  the  deaths 
from  shock,  hemorrhage,  wound  sepsis,  pneumonia,  and 
embolism. 

The  tendency  of  malignant  disease  of  the  jaws  is  to  grow 
into  the  accessory  sinuses  of  the  face  and  toward  the  base 
of  the  skull.  An  intimate  knowledge,  therefore,  of  the 
anatomy  of  these  sinuses  is  necessary  to  the  operating 
surgeon.  Illustrations  of  the  anatomy  of  the  various  sinuses, 
which  may  prove  helpful,  have  been  here  included. 

I  have  made  use  of  all  available  general  medical  literature 
in  the  study  of  this  subject.  I  thank  Dr.  Richard  G.  Wads- 
worth,  Dr.  Robert  M.  Green,  Dr.  William  C.  Quinby,  and 
Dr.  Fred  T.  Murphy  for  assistance  in  the  search  of  the 
literature. 

As  a  basis  for  this  monograph  I  have  studied  with  great 
thoroughness  the  clinical  material  at  the  Massachusetts 
General  Hospital,  and  I  thank  my  associates  upon  the  staff 
of  the  hospital  for  opportunities  for  study.  My  own  surgical 


14  PREFACE 

experience  for  the  past  twenty  years  has  been  helpful  in  the 
study  of  this  subject. 

I  thank  Dr.  Wm.  F.  Whitney,  the  curator  of  the  Warren 
Museum  of  the  Harvard  Medical  School,  for  valuable  assist- 
ance in  the  study  of  specimens. 

I  am  indebted  to  Dr.  Allen  B.  Kanavel,  of  Chicago,  for 
permission  to  use  his  article  on  Leontiasis,  it  being  the  latest 
word  on  this  subject. 

CHARLES  L.  SCUDDER. 

209  BEACON  STREET,  BOSTON,  MASS. 
February,  1912. 


CONTENTS 


CHAPTER  I  PAGE 

EPULIS 17 

CHAPTER  II 

SARCOMA  OF  THE  JAWS ' 40 

CHAPTER  III 
BENIGN  TUMORS  OF  THE  JAWS , 140 

CHAPTER  IV 
THE  ODONTOMATA 162 

CHAPTER  V 

CARCINOMA  OF  THE  JAWS 240 

CHAPTER  VI 

THE  DIAGNOSIS  AND  OPERATIVE  TREATMENT  OF  MALIGNANT  DISEASE 

OF  THE  UPPER  AND  LOWER  JAWS 284 

CHAPTER  VII 
TUMORS  OF  THE  PALATE 319 

CHAPTER  VIII 

LEONTIASIS  OSSEA 333 

CHAPTER  IX 

PROSTHESIS  .  .  .   354 


INDEX  OF  NAMES 375 

INDEX . .  .379 


15 


14  PREFACE 

experience  for  the  past  twenty  years  has  been  helpful  in  the 
study  of  this  subject. 

I  thank  Dr.  Wm.  F.  Whitney,  the  curator  of  the  Warren 
Museum  of  the  Harvard  Medical  School,  for  valuable  assist- 
ance in  the  study  of  specimens. 

I  am  indebted  to  Dr.  Allen  B.  Kanavel,  of  Chicago,  for 
permission  to  use  his  article  on  Leontiasis,  it  being  the  latest 
word  on  this  subject. 

CHARLES  L.  SCUDDER. 

209  BEACON  STREET,  BOSTON,  MASS. 
February,  1912. 


CONTENTS 


CHAPTER  I  PAGE 

EPULIS 17 

CHAPTER  II 

SARCOMA  OF  THE  JAWS 40 

CHAPTER  III 

BENIGN  TUMORS  OF  THE  JAWS 140 

CHAPTER  IV 

THE  ODONTOMATA 162 

CHAPTER  V 

CARCINOMA  OF  THE  JAWS 240 

CHAPTER  VI 

THE  DIAGNOSIS  AND  OPERATIVE  TREATMENT  OF  MALIGNANT  DISEASE 

OF  THE  UPPER  AND  LOWER  JAWS 284 

CHAPTER  VII 

TUMORS  OF  THE  PALATE 319 

CHAPTER  VIII 

LEONTIASIS  OSSEA 333 

CHAPTER  IX 

PROSTHESIS.  .  .   354 


INDEX  OF  NAMES 375 

INDEX.  .   379 


15 


TUMORS  OF  THE  JAWS 


CHAPTER  I 
EPULIS 

CONTENTS  OF  CHAPTER:  Epulis  defined. — Age  of  occurrence. — Sex  fre- 
quency.— Local  causes. — Liability  of  the  two  jaws. — Varieties  of:  Fi- 
brous; Giant-cell. — Symptoms:  Beginning  period;  Well-marked  tumor; 
Period  of  ulceration. — Course  of  epulis  of  two  types. — Prognosis. — • 
Diagnosis. — Treatment. — Summary. 

EPULIS  is  a  topographic  term.  It  is  applied  to  a  new- 
growth  apparently  seated  upon  the  gum  or  upper  edge  of 
the  alveolar  border  of  the 
jaw.  Epulis  really  originates 
from  the  alveolar  periosteum 
or  connective  tissue  beneath 
the  mucous  membrane.  (See 
Figs.  1  and  3.)  It  is  one  of 
the  most  common  tumors  of 
the  jaw  and  one  of  the  least 
malignant.  It  is  a  slowly 
growing  jaw  tumor. 


Fig.  1. — Colored  girl,  aged  six- 
teen. Upper  jaw.  Tumor  one  year. 
Tumor  surrounds  teeth  between 
canine  and  last  molar;  lobulated, 
smooth,  covered  with  mucous  mem- 
brane. Sections :  angiofibroma,  some 
evidence  of  inflammation  (Blood- 
good). 


An  epulis  is  a  border-line 
tumor:  it  lies  midway  be- 
tween inflammation,  on  the 
one  hand,  and  a  neoplasm, 
on  the  other.  When  looked  upon  as  a  neoplasm,  it  is  still  a 
border-line  lesion  between  the  benign  and  the  malignant 
2  17 


18 


TUMORS   OF   THE   JAWS 


connective-tissue  tumors.  It  is  frequently  called  a  sarcoma 
(Bloodgood). 

Age  of  Occurrence. — It  appears  most  often  in  child- 
hood and  young  adults.  In  a  series  of  117  cases,  the  third 
and  fourth  decades  were  most  frequently  involved. 

Sex  Frequency. — In  a  series  of  167  cases  it  occurred 
49  times  in  men  and  118  times  in  women. 

Local  causes  are  recognized  as  important.     The  irri- 


so 


10 


2.0 


50 


GO 


70 


15 

10 

5 


16eAttt 


s+c,u-es 


SOyears 


Fig.  2.— Table  showing  the  frequency,  in  percentage,  according  to  age  of  the 
occurrence  of  sarcomatous  epulis  (167  cases  taken  from  several  clinics). 

tation  of  a  carious  tooth  may  start  an  epulis.  If  a  tooth 
has  been  broken  in  extraction,  the  remaining  root  may 
serve  as  irritation  enough  to  cause  an  epulis  to  grow. 
Trauma  to  a  preexisting  epulis  which  has  been  almost  sta- 
tionary may  cause  it  to  grow  rapidly.  Epulis  may  start 
next  a  normal  tooth. 

Liability  of  the  Two  Jaws. — The  two  jaws  are  about 
equally  liable  to  the  disease.  In  a  series  of  132  cases  61 
were  in  the  upper  jaw  and  71  were  in  the  lower  jaw. 


EPULIS 


19 


When  the  teeth  are  simply  pushed  apart,  the  growth 
is  usually  less  malignant  than  when  the  teeth  are  lifted  or 
pushed  directly  up.  When  the  teeth  are  lifted  and  loosened 
by  the  growth,  the  tumor  is  more  likely  to  have  originated 
within  the  bone.  The  tumor  originating  within  the  bone 
is  often  a  giant-cell  epulis. 


Fig.    3. — Microscopic    appearances   of    a    typical    giant-cell    epulis    (W.    F. 

Whitney). 


Epulis  appears  in  order  of  frequency  near  the  canine, 
the  bicuspids,  the  first  molars,  and  the  incisors.  It  almost 
never  appears  behind  or  fastened  to  the  root  of  the  last 
molar.  (See  Figs.  18  and  19,  illustrating  an  exception  to 
the  common  experience.) 


20  TUMORS   OF   THE    JAWS 

Epulis  stands  between  the  slightly  malignant,  really  be- 
nign connective-tissue  tumors,  and  the  malignant  connec- 
tive-tissue tumors  (Bloodgood). 

The  two  varieties  of  epulis  are  the  fibrous  epulis 
and  the  giant-cell  epulis  or  sarcomatous  epulis.  The  giant- 
cell  variety  of  epulis  is  the  most  common  form  of  epulis 
(Figs.  3,  4,  6,  and?). 


Fig.  4. — Microscopic  appearances  of    a  typical  giant-cell  epulis    (\V.   1  . 

Whitney). 


The  fibrous  epulis  is  ordinarily  of  small  size,  projecting 
between  two  teeth,  which  it  loosens.  It  then  spreads  out 
over  the  alveolar  border  (Figs.  5,  8,  and  13). 

The  fibrous  epulis  may  become  calcified  extensively  or 
in  limited  areas  throughout  its  substance. 

The  fibrous  epulis  is  not  very  vascular  (see  Fig.  18), 
consequently  the  mucous  membrane  over  it  is  normal  in 
appearance.  At  a  later  period  in  the  growth  of  the  fibrous 
epulis  there  may  appear  areas  of  necrosis  and  ulceration 


PLATE  III 


Epulis  of  the  upper  jaw.    Xote  the  color,  mucous  membrane  evidently  intact, 
situation  of  the  tumor,  one  tooth  already" extracted  (after  Mikulicz). 


EPULIS  21 

from  pressure  of  the  teeth  upon  the  surface  of  the  growth. 
The  fibrous  epulis  arises  from  the  alveolar  dental  periosteum 
or  the  connective  tissue  between  the  bone  of  the  alveolar 
border  and  the  mucous  membrane  of  the  gum  surrounding 
the  teeth  (Bloodgood).  It  often  appears  that  the  epulis 
arises  from  the  interior  of  the  tooth  socket.  It  may  arise 


Fig.  5. — Microscopic  appearances  of  a  typical  fibrous  epulis  (W.  F.  Whitney). 


from  a  normal  tooth  socket,  whereas  from  the  socket  of  a 
carious  tooth  the  giant-cell  epulis  more  often  seems  to 
develop. 

The  softer  giant-cell  sarcomatous  epulis  forms  a 
soft,  red,  irregularly  rounded  mass,  seen  at  the  gum  border 
in  the  inside  of  the  tooth.  In  it  are  many  vessels;  conse- 


22 


TUMORS   OF   THE   JAWS 


Fig.  6. 


Fig.  7. 

Figs.  6  and  7. — Photomicrographs  of  giant-cell  epuli.s.  Fig.  6  represents 
a  low-power  view;  Fig.  7,  one  in  which  details  are  more  highly  magnified 
(from  originals,  loaned  by  Joseph  C.  Bloodgood). 


EPULIS  23 

quently  it  bleeds  easily  upon  slight  trauma.     A  very  vas- 
cular epulis  may  pulsate. 

The  epulis  rarely  grows  to  a  large  size,  for  the  patient 
is  usually  operated  upon  early.  The  bone  is  rarely  invaded 
by  epulis.  Cases  are  recorded  in  which  the  tumor  has 
grown  upward  and  invaded  other  parts,  or  has  protruded 


Fig.  8. — Fibrous  epulis  of  the  upper  jaw,  alveolar  margin.     Note  the  dry 
firm-looking  tumor  (Perthes). 


from  the  mouth  and  caused  great  deformity.  It  resembles, 
under  these  conditions  of  rapid  and  destructive  growth, 
the  more  malignant  types  of  sarcoma. 

There  may  be  spicules  of  bone  through  the  giant-cell 
epulis.  These  spicules  of  bone  suggest  the  origin  of  the 
tumor  from  periosteal  cells  which  are  capable  of  forming 


24  TUMORS   OF   THE   JAWS 

new  bits  of  bone.     There  may  be,  too,  cysts  found  upon 
section  of  these  tumors. 

Gunzert  has  called  attention  to  the  fact  that  epulis 
which  has  remained  quiescent  may  begin  to  grow  rapidly 
during  pregnancy.  Recurrences  of  epulis  are  likely  to 
appear  during  pregnancy  and  to  grow  less  rapidly  after 
confinement. 


Fig.  9. — A  case  of  chloroma  of  the  jaw.  These  photographs  (see  Fig.  10) 
represent  the  condition  six  months  after  the  onset  of  the  disease.  The  patient 
lived  one  year  after  this  time.  There  were  enlarged  glands  in  the  neck.  The 
growth  extended  across  the  roof  of  the  mouth,  and  the  oral  mucous  membrane 
was  universally  hypertrophied  so  that  the  patient  could  take  only  liquid  food 
for  some  months  before  death  (case  of  S.  L.  McCurdy).  (See  Trans,  of  Asso. 
of  Am.  Physicians,  1904,  vol.  xix,  Annals  of  Surgery,  Jan.,  1910,  and  Aug.,  1910.) 

Symptoms. — Three  periods  are  distinguishable  in  the 
growth  of  epulis  (Gruet) : 

1.  The  beginning  period  (the  tumor  is  not  easily  recog- 
nized). 

2.  The  period  of  well-marked  tumor. 


EPULIS 


25 


3.  The  period  of  ulceration — a  rare  ending  for  epulis. 

i.  The  Beginning  Stage. — At  this  time  we  cannot 
find  a  tumor:  it  is  not  yet  visible.  The  patient  seeks  aid 
from  a  physician  solely  on  account  of  the  functional  dis- 
tress occasioned  by  the  growth. 

If  the  tumor  arises  in  the  socket  of  the  tooth,  it  presses 
on  the  nerve  at  the  root  and  causes  a  toothache  or  neu- 
ralgia, or  simply  a  feeling  of  pressure.  The  pain  may  not 


Fig.  10. — A  case  of  chloroma  of  the  jaw.  A  rare  condition,  affecting  here 
both  jaws  on  lingual  and  buccal  aspects.  The  growth  suggests  a  leukemic 
lymphoma,  resembles  in  some  ways  a  sarcoma,  in  other  ways  a  myeloid  pro- 
liferation not  easily  confused  with  ordinary  epulis  (case  of  S.  L.  McCurdy). 
(See  Trans,  of  Asso.  of  Am.  Physicians,  1904,  vol.  xix,  Annals  of  Surgery,  Jan., 
1910,  and  Aug.,  1910.) 

be  limited  to  any  particular  tooth,  but  may  radiate  through- 
out the  surrounding  gum  and  cheek  and  jaw. 

Upon  examination  of  each  tooth  carefully  one  tooth  will 
be  found  to  be  more  painful  than  the  others,  especially  after 
the  paroxysm  of  pain  has  ceased.  It  will  be  in  the  alveo- 
lus of  this  particular  tooth 'that  the  tumor  will  be  found  to  be 
developing. 


Fig.  11. — Giant-cell  epulis,  rapidly  growing  type.  This  tumor  had  been 
but  five  weeks  developing.  Note  the  vascular  (dark)  tumor.  This  tumor 
bleeds  readily  when  touched  (Perthes). 


Fig.  12. — Epulis,  giant-cell.  Note  the  situation.  Note  the  fullness  of 
the  tumor  under  the  alveoli  of  the  incisor  teeth  roots.  These  teeth  are  loose. 
Note  the  soft  appearance  of  this  tumor.  The  teeth  situated  in  the  tumor  and 
on  it  are  almost  seen  to  be  movable  (Partsch). 

26 


EPULIS 


27 


As  the  tumor  grows  it  may  gradually  raise  the  tooth 
above  the  level  of  the  adjoining  teeth.  The  tooth  may  even 
be  pushed  out  of  its  socket  completely.  The  patient  goes 
to  a  dentist.  If  there  is  a  "bad  tooth"  in  the  immediate 
neighborhood,  the  dentist  extracts  it  or  he  applies  local 
remedies.  If  the  tooth  is  extracted,  there  is  instant  relief. 


Fig.  13.— Typical  fibroid  epulis  (S.  L.  McCurdy). 

The  patient  thinks  himself  well  until  he  sees  a  small  tumor 
growing  out  of  the  alveolus. 

2.  The  Established  Period,  the  Period  of  the 
Tumor. — The  epulis  appears  as  a  small,  smooth,  rounded, 
red,  finely  lobulated,  vascular  tumor.  (See  Figs.  8  to  12.) 

Its  size  is  variable.  It  may  be  as  small  as  a  pea  or  the 
size  of  a  cherry  or  an  olive.  (See  Figs.  11,  12,  13.)  If  the 
patient  has  had  nothing  done  for  it  and  has  allowed  it  to 


28 


TUMORS    OF    THE    JAWS 


grow  uninterruptedly  for  some  time,  it  may  attain  great 
size.  (See  Figs.  21,  23.)  Ordinarily,  the  growth  is  small- 
like  an  olive  or  smaller. 

The  epulis  is  always  seated  upon  the  alveolar  border  or 
edge  near  the  neck  of  the  teeth  or  empty  teeth  sockets. 
One  or  more  teeth  are  usually  included  in  the  tumor  (Fig. 


Fig.  14.  Fig.  15. 

Fig.  14. — Fibrous  epulis  of  the  lower  jaw. 

Fig.' 15. — Same  as  Fig.  14,  showing  the  attachment  and  probable  origin  from 
the  inner  side  of  the  alveolus. 


Fig.  16.  Fig.  17. 

Fig.  16. — Epulis  of  the  upper  jaw. 

Fig.  17. — Same  as  Fig.  16,  showing  the  development  of  the  tumor  on  the  inner 
side  of  the  alveolar  process. 

12).  The  swelling  is  first  seen  on  the  inner  side  of  the  alve- 
olar process.  (See  Figs.  14,  15,  16,  and  17.)  The  tumor 
extends  to  the  outer  side  eventually,  but  almost  always 
involves  the  inner  side  most  definitely. 

There  is  little  or  no  infiltration  of  the  mucous  membrane 


EPULIS 


29 


Fig.  18. — Giant-cell  epulis  of  right  lower  jaw;  painless  growth  three  years 
in  white  male,  aged  fifty.  The  last  two  molars  have  been  lost,  after  the 
appearance  of  the  tumor  (from  original,  loaned  by  Joseph  C.  Bloodgood). 


Fig.  19. — Fresh  specimen  showing  section  and  surface  of  tumor  illustrated 
in  Fig.  18.  Giant-cell  epulis  (from  original,  loaned  by  Joseph  C.  Blood- 
good). 


30  TUMORS    OF   THE    JAWS 

or  gum.  This  fact  serves  to  differentiate  it  from  an  inflam- 
matory process  (Bloodgood).  The  epulis  may  at  first  be 
thought  to  be  an  ordinary  "gum-boil."  It  may  be  that 
the  immediate  occasion  of  the  detection  of  an  epulis  is  the 
patient  coming  to  the  physician  to  have  the  supposed  gum- 
boil lanced. 

In  epulides  of  the  upper  jaw  the  thickening  or  infiltra- 


Fig.  20. — Giant-cell  epulis  of  the  alveolar  border  of  the  jaw  (Perthes). 

tion  will  extend  farther  than  in  the  lower  jaw,  often  extend- 
ing over  on  to  the  hard  palate.  The  gum  in  the  region  of 
an  epulis  is  perfectly  healthy.  Epulis  rarely,  if  ever,  orig- 
inates beyond  the  last  molar  tooth.  (See  Figs.  18  and  19.) 
Epulis  is  most  commonly  found  about  the  canine  and 
bicuspid  and  first  molar  teeth;  quite  rarely  about  the 
incisor  teeth  (Fig.  20). 

Broca  reports  a  fibrous  epulis  that  grew  so  large  in 
eight  years  that  the  nose  disappeared  within  the  tumor. 

Listen  records  a  case  (see  Figs.  21  and  22)  which  illus- 


Fig.  21.— Fibrous  epulis  of  the  upper  jaw.  Duration  of  growth,  eight 
years.  Removed  successfully  by  Listen  in  1836.  (Listen,  "LondonJLancet," 
Nov.  5,  1836.)  Note  the  firm,  solid  appearance  of  the  tumor  (Heath). 


Fig.  22. — Same  patient  as  shown  in  Fig.  21,  after  the  removal  of  the  large 

fibrous  epulis  (Heath). 

31 


32 


TUMORS    OF    THE    JAWS 


t rates  the  great  size  to  which  the  fibrous  epulis  may  grow. 
This  was  removed  successfully.  There  is  no  true  hemor- 
rhage from  an  epulis,  but  there  may  be  an  oozing  of  blood 
occasioned  by  trauma  of  the  surface  of  so  vascular  a  growth. 
The  case  of  Bannister  is  of  interest  in  this  connection.  (See 
Figs.  23,  24,  and  25.) 

Palpation  finds  the  tumor  closely  attached  to  the  bone. 


Fig.  23. — Epulis  of  lower  jaw 
which  has  attained  enormous  size 
(Bannister,  Barbados,  W.  I.). 


Fig.  24. — Epulis  of  lower  jaw. 
A  side  view  of  Fig.  23.  Note  the  en- 
croachment of  the  tumor  upon  the 
opening  of  the  mouth  (Bannister, 
Barbados,  W.  I.). 


The  attachment  is  sometimes  broad,  but  more  often  narrow . 
If  the  growth  starts  from  the  socket  of  a  tooth,  a  distinct 
pedicle  of  the  tumor  will  be  found. 

The  consistence  of  these  epulides  is  dependent  upon 
their  vascularity  and  upon  the  amount  of  fibrous  tissue 
present.  The  more  vascular,  the  more  soft  and  fluctuating 
they  feel.  (See  Fig.  26.) 


EPULIS 


33 


3.  Period  of  Ulceration. — Epulis  rarely  ulcerates, 
but  sometimes  does.  The  picture  may  be  complicated  if 
ulceration  occurs.  The  ulceration  is  like  that  of  sarcoma, 
rather  than  that  associated  with  carcinoma.  It  is  the 
ulceration  caused  by  pressure  rather  than  by  infiltration. 
The  mucous  membrane,  distended  over  the  tumor  and 
irritated  by  friction,  breaks  down  through  lack  of  circu- 


Fig.  25. — Epulis  of  the  lower  jaw.     Appearance  after  removal  of  the  tumor 

(Bannister) . 

lation,  and  the  irregular  opening  thus  caused,  with  edges 
undermined,  permits  of  a  protrusion  of  the  growth. 

Following  such  ulceration  glandular  enlargement  may 
occur,  due  usually  to  a  secondary  infection. 

The  course  of  epulis  of  the  fibrous  type  is  very  slow 
indeed.  After  years  of  growth  the  tumor  may  attain  con- 
siderable size.  The  softer,  more  vascular,  giant-cell 
type  of  epulis  is  more  rapidly  growing. 


34  TUMORS    OF    THE    JAWS 

Certain  of  the  giant-cell  growths  may  become  more 
malignant,  invading  the  jaw  and  manifesting  all  the  signs 
of  a  truly  malignant  sarcoma.  The  recurrences  of  what 
seem  to  be  simple  epulis  are  very  apt  to  be  more  malignant 
than  the  original  growth. 

The  prognosis  of  epulis  after  the  operation  of  excision 
is  good.  The  fibrous  form  never  recurs  once  it  is  removed. 


Fig.  26. — Fibrous  epulis  developing  in  a  woman  fifty-nine  years  old.  It 
had  been  growing  for  about  two  years.  Note  that  the  tumor  seen  within  the 
mouth  has  pushed  the  cheek  outward.  The  nasolabial  fold  is  obliterated  on 
the  side  of  the  tumor  (Perthes). 

The  giant-cell  type  of  epulis  does  not  recur  if  the  tumor  and 
its  seat  and  a  bit  of  the  bone  beneath  its  seat  be  removed. 
Very  rarely  an  alveolar  epulis  may  develop  as  rapidly 
as  a  central  sarcoma,  and  grow  with  terrible  speed,  the 
most  radical  operation  failing  to  check  the  growth  and  pre- 
vent a  fatal  end. 


EPULIS  35 

Certain  epulides  after  a  slow  growth  for  a  long  time  will 
suddenly  begin  to  grow  rapidly  and  develop  in  a  dangerous 
way. 

The  prognosis  in  epulis  of  the  sarcomatous  type  should 
be  guarded.  Benignancy  is  the  rule,  but  malignancy  may 
be  the  rare  exception. 

Diagnosis. — In  the  early  stage  all  causes  of  neuralgia 
must  be  considered  before  it  can  with  defmiteness  be  stated 
that  in  the  particular  case  it  is  due  to  epulis.  Local  con- 
ditions giving  rise  to  pain  must  also  be  considered — a 
carious  tooth,  sensitive  to  heat  and  cold,  a  periostitis  about 
the  tooth,  sensitive  to  pressure  and  percussion.  Each  of 
these  conditions  must  be  reckoned  with.  Caries  of  the 
tooth  may  be  the  beginning  of  epulis. 

In  a  young  individual  an  odontoma  and  a  cyst  about  the 
root  of  a  tooth  are  to  be  considered. 

Lymphatic  involvement  is  absent  ordinarily  unless 
there  be  some  secondary  infection  present. 

Granulomata  or  papillary  growths  from  a  malignant 
base  must  not  be  confused  with  an  epulis. 

Haasler  has  described  root  granulomata — granulomata 
attached  to  and  starting  from  the  roots  of  carious  teeth. 

A  gum-boil  or  dental  abscess — alveolar  abscess — is  recog- 
nized by  its  local  tenderness,  its  circumscribed  edema  and 
infiltration,  and  the  presence  of  pus. 

Fungosity  of  the  gums  need  not  be  confused  with  epulis. 

Actinomycosis,  which  usually  begins  in  a  carious  tooth 
socket,  soon  has  distinctive  characteristics,  such  as  the  ray 
fungus  in  the  puriform  discharge,  great  swelling  of  the  gums 
extending  to  the  body  of  the  jaw,  and  swelling  of  the  sub- 
maxillary  region. 


36  TUMORS    OF   THE   JAWS 

Retained  wisdom  teeth  may  be  confusing  in  diagnosis  at 
first  because  they  cause  pain  and  swelling.  In  a  tumor  of 
the  gum  one  should  be  sure  that  no  teeth  are  missing  from 
the  patient's  jaws.  An  odontoma  (dentigerous  cyst  and 
an  adamantine  epithelioma)  growing  at  first  within  the 
jaw,  later  coming  to  the  alveolar  surface,  projecting  be- 
neath the  gum,  may  suggest  an  epulis.  Usually  one  or 
more  teeth  are  absent.  Any  tumor  which  appears  in  the 
jaw  after  the  full  development  of  all  the  teeth  cannot  be 
an  odontoma. 

Sarcoma  of  the  jaw,  even  if  it  starts  in  the  alveolar 
border,  spreads  so  rapidly  to  the  body  of  the  jaw  that  it  is 
ordinarily  distinguishable  from  an  epulis. 

Carcinoma  of  the  mucous  membrane  of  the  alveolar 
border  is  a  common  disease  and  may  be  mistaken  for  epulis. 
The  early  ulceration,  the  rather  rapid  progress,  the  easy 
bleeding,  the  fetid  characteristic  discharge  from  the  mouth, 
the  early  involvement  of  the  submaxillary  lymphatics,  the 
severity  of  the  pain,  the  constitutional  disturbance — all 
present  a  picture  characteristic  of  carcinoma  and  not 
characteristic  of  epulis.  The  ulceration  of  sarcomatous 
epulis  is  quite  rare  and  presents  a  different  picture.  It 
occurs  from  mechanical  causes,  is  not  complicated  by 
hemorrhage  nor  usually  by  glandular  enlargement,  and 
its  progress  is  much  slower  and  without  any  impairment 
of  the  general  health. 

With  an  epulis  the  anatomic  characteristics  of  the  jaw 
are  maintained;  the  sulcus  between  lip  and  jaw,  and  that 
between  cheek  and  jaw,  remain  normal.  The  epulis  tumor 
rests  on  the  alveolar  ridge;  it  does  not  eat  into  the  bone. 

Having  determined  that  the  growth  is  an  epulis,  the 


EPULIS  37 

question  arises,  Is  it  a  fibrous  epulis,  or  a  giant-cell  epulis 
more  nearly  resembling  a  sarcoma? 

The  fibrous  epulis  is  well  circumscribed ;  it  is  uniformly 
firm  and  smooth,  without  projections.  The  mucous  mem- 
brane over  it  is  usually  perfectly  healthy.  It  grows  very 
slowly  and  rarely  reaches  great  size.  It  demands  less 
radical  treatment  than  the  more  common  giant-cell  epulis. 

The  giant-cell  epulis  has,  on  the  other  hand,  a  deeper  red 
venous  color,  appears  more  vascular,  and  bleeds  easily. 
It  also  may  appear  like  erectile  spongy  tissue.  There  are 
projections  and  irregularities  on  the  surface.  It  resembles 
at  times  granulation  tissue.  The  consistence  is  not  uni- 
form. In  certain  places  it  is  hard;  in  other  parts  it  is  soft. 
It  grows  more  rapidly  than  the  fibroma,  and  attains  a  larger 
size.  It  is  the  common  form  of  epulis. 

Treatment. — Epulis  is  a  tumor  that  can  be  cured. 

As  ordinarily  treated,  the  tendency  is  for  epulides  to 
recur  locally.  In  fibrous  epulis  excision  and  cauterization 
of  the  base  of  the  growth  are  sufficient  to  effect  a  cure. 

In  the  case  of  a  giant-cell  epulis  the  adjacent  teeth  and 
a  portion  of  the  alveolar  process  of  the  jaw  should  be  re- 
moved, together  with  the  overlying  gum  and  mucous  mem- 
brane. 

Patients  having  been  operated  on  for  epulis  should  be 
carefully  watched  at  intervals  until  all  likelihood  of  recur- 
rence is  past.  The  recurrence  of  an  epulis  is  likely  to  prove 
more  obstinate  in  removal  than  the  original  growth. 

Shaving  off  the  epulis  and  applications  of  nitrate  of 
silver  are  unsatisfactory.  The  growth  often  seems  stimu- 
lated thereby.  Sometimes,  in  extracting  the  tooth  from 
the  alveolus  of  which  the  epulis  springs,  the  whole  epulis 


38  TUMORS   OF   THE   JAWS 

is  attached  to  the  root  of  the  tooth  and  comes  away  with 
the  tooth. 

Removal  should  be  early  and  complete. 

The  Safest  Treatment  for  Epulis. — Draw  the  tooth 
situated  on  either  side  of  the  growth,  notch  the  bone  with 
a  thin  small  saw  on  both  sides  of  the  tumor,  and  with  a 
chisel  remove  the  alveolar  border  bearing  the  growth  thus 
marked  out. 

In  a  certain  few  cases  I  should  agree  with  Bloodgood 
that  if  it  is  important  to  save  a  normal  tooth  next  an  epulis, 
and  if  the  anatomic  relations  of  the  growth  to  the  alveolar 
process  and  tooth  socket  are  favorable,  a  removal  by  the 
knife  and  thorough  cauterization  with  the  actual  cautery 
are  justifiable.  This  may  be  done  safely,  however,  in  my 
opinion,  in  comparatively  few  cases. 

Drawing  the  teeth  assists  in  the  eradication  of  the 
growth,  and  also  (Salter)  causes  a  wasting  of  the  alveolus 
and  very  materially  assists  in  combating  recurrence. 

It  is  never  necessary  to  make  a  complete  section  through 
the  lower  jaw  for  the  removal  of  an  ordinary  epulis.  It 
is  wise  to  avoid  an  incision  from  the  angle  of  the  mouth  to 
reach  a  difficult  epulis.  It  is  better  to  incise  at  the  midline 
of  the  lip.  This  will  rarely  be  necessary. 

Results  in  several  clinics  after  operation : 

The  radical  operation  in  18  cases  at  the  Heidelberg 
clinic,  according  to  Wassermann,  resulted  in  15  cures  and 
3  recurrences. 

Gunzert  reports  38  cases — 35  well  and  3  recurrences. 
He  also  records  one  death  from  met  astatic  sarcoma  of 
the  brain  following  extirpation  of  a  fibrosarcomatous  epulis 
of  the  jaw. 


EPULIS  39 

Bloodgood  has  never  known  epulis  to  give  rise  to  me- 
tastasis. Of  40  operations  for  epulis  at  the  Johns  Hopkins 
Hospital  clinic,  all  have  remained  well,  including  the  recur- 
rent cases. 

At  the  Massachusetts  General  Hospital  clinic  there  were 
19  cases  of  epulis  during  a  ten-year  period.  Those  in  which 
the  alveolar  border  was  removed  have  had  no  recurrence. 
I  know  of  no  metastasis  at  the  Massachusetts  General 
Hospital  clinic  in  epulis  cases. 

Recurrences  after  operation  are  likely  to  occur  if  the 
base  and  origin  of  the  growth  is  not  removed.  Otherwise 
recurrence  is  unusual. 

Summary. — An  epulis  is  a  connective-tissue  tumor 
midway  in  malignancy  between  a  fibroma  and  a  giant-cell 
sarcoma.  It  is  seated  on  the  alveolar  border  of  the  jaws 
about  the  teeth.  It  occurs  in  very  young  adults.  It 
occurs  in  girls  more  often  than  in  boys.  It  is  often  caused 
by  local  irritation  about  the  teeth.  It  may  be  fibrous  or 
contain  many  giant-cells.  It  is  often  mistaken  in  its  early 
stages  for  a  gum-boil.  It  is  locally  malignant.  It  is  cura- 
ble by  operation.  Metastases  do  not  occur.  It  may  be 
confused  with  an  alveolar  giant-cell  sarcoma  or  a  car- 
cinomatous  ulcer.  It  should  be  thoroughly  removed. 


CHAPTER  II 
SARCOMA  OF  THE  JAWS 

CONTENTS  OF  CHAPTER:  (A)  Facts  regarding  sarcoma  of  both  upper  and  lower 
jaws:  Origin  of  sarcoma. — Histologic  groups. — Rate  of  growth. — The 
relations  of  sarcoma  to  the  age  of  the  individual. — Occurrence  in  the  two 
j;i\vs  according  to  age  periods. — Material  studied. — Central  and  periosteal 
varieties. — Mixed  sarcoma. — Round-cell  sarcoma. — Part  of  jaw  first 
attacked. — Relative  frequency  of  occurrence  in  male  and  female. — Etio- 
logic  importance  of  trauma.— Melanosarcoma.  (B)  Sarcoma  of  the  upper 
jaw:  Symptoms — (1)  Early  period:  Troubles  with  the  teeth;  The  an- 
trum;  Nasal  polyp — (2)  Well-established  period — (3)  Late  period. — Sum- 
mary of  clinical  picture. — Characteristic  signs  of  sarcoma  of  the  upper  jaw. 
— Diagnosis. — Prognosis. — Mortality  from  operation  per  se. — Causes  of 
death  after  operation:  (a)  Sepsis;  (6)  Hemorrhage;  (c)  Pneumonia; 
(d)  Shock. — Partial  operation  vs.  total  operation. — Significance  of  early 
vs.  late  operation. — Ultimate  cures  following  operation  for  sarcoma  of 
the  upper  jaw. — Cases  of  sarcoma  from  the  Massachusetts  General  Hos- 
pital clinic. — Should  operation  be  done  in  every  case? — Table  of  cases  of 
sarcoma  of  jaws  occurring  at  the  Massachusetts  General  Hospital  clinic. — 
Necessity  for  dissecting  the  neck  in  sarcoma.— When  do  recurrences  ap- 
pear and  where? — The  time  after  operation  of  the  appearance  of  the  re- 
currence.— The  necessity  for  the  removal  of  the  eye  and  the  orbital  plate. 
—Table  of  results  of  operative  treatment  of  sarcoma  of  the  upper  and 
lower  jaws  from  European  clinics.  (C)  Sarcoma  of  the  lower  jaw:  Kinds 
of  sarcoma. — Rate  of  growth. — Operative  mortality. — Case  of  sarcoma  of 
the  lower  jaw  followed  by  carcinoma. — Causes  of  death  after  operation. — 
Ultimate  results  of  operation  for  sarcoma  of  the  lower  jaw. — End  results 
of  cases  of  lower  jaw  sarcomata  from  the  Massachusetts  General  Hospital 
clinic. — The  duration  of  the  disease  previous  to  operation. — Detailed 
account  of  some  of  the  cases  of  lower  jaw  sarcomata  studied. — Detailed 
account  of  certain  inoperable  sarcomata  of  the  lower  jaw.  (D)  Tin  tn-ot- 
meni  of  sarcoma  of  the  upper  and  lower  jaw. 

(A)  FACTS  REGARDING  SARCOMA  OF  BOTH  UPPER 
AND  LOWER  JAWS 

SARCOMA  is  the  new-growth  of  the  connective-tissue 
group  of  tumors  most  often  found  in  bone.  It  is  malignant, 
that  is,  it  reappears  where  it  has  been  apparently  completely 
removed,  and  it  produces  metastases  through  the  blood- 
channels. 

Origin.— Sarcoma  may  arise  from  the  marrow  of  the 
bone  or  apparently  from  the  periosteum  covering  the  bone, 

40 


SARCOMA   OF   THE   JAWS  41 

or  from  the  walls  of  the  blood-vessels  of  the  bone.  If  it 
arises  from  the  medulla,  it  is  called  a  central  (Virchow) 
or  medullary  sarcoma;  if  from  the  periosteum,  it  is  called 
a  peripheral  or  periosteal  (Virchow)  sarcoma;  and  if  from 
the  blood-vessel  wall,  it  is  called  a  perithelioma.  The 
perithelioma  is  relatively  uncommon. 

Histologic  Groups. — The  sarcomata  are  grouped  his- 
tologically  according  to  the  predominance  of  certain  forms 
of  cells.  Many  of  the  sarcomata  contain  multiple  cell 
forms,  and  it  is  sometimes  difficult  to  classify  definitely  the 
individual  tumors.  The  giant-cell,  round-cell,  and  spindle- 
cell  forms  are  the  usual  microscopic  varieties.  Certain 
bones  and  limited  portions  of  certain  bones  are  the  seats 
of  sarcomata  of  a  definite  cell  type;  for  instance,  the  giant- 
cell  sarcoma  is  found  most  frequently  in  the  upper  end  of 
the  tibia  and  in  the  jaw. 

Rate  of  Growth. — The  rate  of  growth  of  the  sarcoma 
is  associated  with  the  form  of  the  predominant  cell.  Thus, 
the  fibrosarcoma  and  the  spindle-cell  sarcoma  are  of  less 
rapid  growth,  hence  less  malignant,  than  the  round-cell 
sarcoma.  The  round-cell  sarcoma  is  very  vascular  and 
malignant.  The  perithelial  angiosarcoma  is  the  most 
malignant  of  the  jaw  sarcomata.  The  giant-cell  sarcoma 
is  the  least  malignant  type  of  sarcoma  (Koenig). 

The  Relations  of  Sarcoma  and  Age. — Sarcoma  of 
the  jaw  is  a  new-growth  of  youth  and  young  adult  life.  It 
occasionally  appears  in  old  age.  Estlander  records  a  case 
at  sixty-nine  years  of  age. 

Sarcoma  is  quite  common  in  children,  but  sarcoma  of 
the  jaws  is  extremely  rare  in  childhood.  Dauphin  in  1902 
finds  only  11  cases  occurring  in  the  jaws  of  children.  A 


42 


TUMORS    OF   THE    JAWS 


case  of  sarcoma  of  the  upper  jaw  in  a  child  ten  years  old 
is  illustrated  in  Figs.  90  and  94.  In  childhood  the  cases 
have  usually  occurred  between  six  and  fourteen  years  of 
age.  There  is  one  case  of  sarcoma  of  the  upper  jaw  re- 
corded by  Williams  in  a  child  three  and  a  half  years  old. 

The  form  occurring  in  infancy  and  childhood  is  the 
giant-cell  variety.  Giant-cell  sarcoma  is  rather  unusual 
after  thirty-five  years  of  age.  Spindle-cell  and  round-cell 
sarcomata  most  often  occur  in  adult  life  and  old  age. 

The  occurrence  of  sarcoma  in  the  two  jaws  ac- 
cording to  age  periods  is  illustrated  by  the  accompany- 
ing tabulation: 


Bo 

ra  JAWS.            UPPER 

JAW. 

Low 

EB  JAW. 

AGE  AT 
OPERATION.           Birn. 

Batza- 
roff.        Martens. 

Stein. 

Behm. 

Schmidt. 

TOTAL. 

PER 

CENT. 

1-10    .                       2 

2                1 

5 

2 

I 

1Q 

0  C 

11-20.  ...                  2 

4                2 

6 

4 

Q 

91 

14   1 

21-30...                 6 

7             3 

8 

9Q 

1Q  £\ 

31-40....               7 

7              5 

5 

9 

OQ 

ion 

41-50.  . 

9              3 

5 

9 

1  7 

nc 

51-60                      3 

4              6 

9 

7 

9 

1  A  O 

61-70                      2 

7 

9 

9 

1  Q 

o  c 

71-80  
81-90  

1 

1 

i 

2 

1 

1.4 
0.7 

The  largest  number  of  cases  appeared  under  fifty  years 
of  age. 

Iii  the  Massachusetts  General  Hospital  series  of  cases 
of  sarcoma  of  the  upper  and  lower  jaws  the  number  of  cases 
according  to  age  periods  is  interesting: 

From    1  year   to  10  years there  were  2  cases 

From  10  years  to  20  years there  were  4  cases 

From  20  years  to  30  years there  were  4  cases 

From  30  years  to  40  years there  were  3  cases 

Prom  40  years  to  50  years there  were  6  cases 

From  50  years  to  60  years there  were  4  cases 

From  60  years  to  70  years there  were  3  cases 


SARCOMA    OF    THE    JAWS 


43 


There  was  a  total  of  26  cases.  Nineteen,  or  more  than 
half,  occurred  under  fifty  years  of  age. 

Material  Studied. — At  the  Massachusetts  General 
Hospital  clinic  there  are  recorded  32  cases  of  sarcoma  of 
the  jaws  exclusive  of  epulis.  It  is  upon  this  clinical  mate- 
rial and  upon  the  literature  that  this  study  of  sarcoma  of 
the  jaws  is  based.  Of  these  32  cases  of  sarcoma  of  the 


Fig.  27. — Periosteal  osteosarcoma  of  the  lower  jaw,  inner  view:  A,  Con- 
dyle;  B,  coronoid  process;  C,  incisor  tooth;  D,  D,  tumor;  E-F,  line  of  transverse 
section.  Some  bony  tissue  lies  in  the  walls  of  the  tumor.  Osteoid  sarcoma 
(Warren  Museum,  No.  9582). 


jaws,  15  cases  occurred  in  the  upper  jaw  and  17  in  the  lower 
jaw.  Nineteen  of  these  cases  of  sarcoma  occurred  in  men 
and  13  occurred  in  women. 

In  the  jaw,  sarcoma  is  a  little  less  common  than  car- 
cinoma. Especially  is  this  true  of  the  upper  jaw.  Sar- 
coma is  more  common  in  the  lower  than  in  the  upper  jaw. 


44  TUMORS    OF   THE    JAWS 

Sarcoma  begins  in  the  jaw  itself;  it  is  a  true  tumor  or  new- 
growth  of  bone. 

Central  and  Periosteal  Varieties. — The  central  sar- 
coma of  the  jaw  is  usually  of  the  giant-cell  type.  As  it 
grows  it  causes  a  softening  of  the  marrow  and  an  absorp- 
tion of  the  bone.  This  destruction  of  bone  by  the  central 
growth  from  within  is  characteristic  of  tumors  of  central 
origin.  When  the  growth  reaches  the  periosteal  covering, 
a  protective  thickening  of  the  periosteum  occurs,  and  this 
shell  of  periosteal  new  bone  serves  as  a  bony  capsule  for 


Fig.  28.— White  male,  aged  thirty-six.  Tumor  two  years;  slow  growth. 
although  the  patient  has  made  two  cuts  into  it.  Tumor  surrounds  incisor 
teeth.  Soft,  elastic,  no  ulceration  of  mucous  membrane.  Sections:  typical 
giant-cell  sarcoma  (Bloodgood). 

the  new-growth.  After  this  capsule  is  destroyed  and  broken 
through  by  the  sarcoma,  the  soft  parts  are  invaded.  (See 
Figs.  32,  33.) 

If  a  giant-cell  sarcoma  has  its  initial  appearance  else- 
where than  at  the  alveolar  margin,— that  is,  if  it  starts 
within  the  body  of  the  jaw  centrally— it  is  often  difficult 
to  differentiate  it  from  a  benign  growth  of  central  origin, 


SARCOMA   OF   THE   JAWS  45 

for  the  inferior  maxilla  will  have  been  expanded  very  much 
as  it  is  by  a  benign  cystic  tumor. 

The  peripheral  or  periosteal  sarcoma  is  seen  to  start 
from  the  periosteum,  and,  as  Perthes  states,  the  bone 
stands  unharmed,  surrounded  completely  by  disease  (see 
Fig.  29),  whereas  the  central  sarcoma  destroys  the  interior 


Fig.  29. — Periosteal  round-cell  sarcoma  of  the  lower  jaw.  Transverse 
section  of  jaw  and  tumor.  Note  the  tumor  surrounding  the  bone  (X)>  which 
remains  intact,  untouched  by  the  sarcoma.  D,  Mass  of  tumor  (Leipsic 
clinic). 


of  the  jaw-bone  and  the  growth  remains  surrounded  by  a 
thin,  bony,  shell-like  protective  covering.  In  the  one 
instance  the  jaw  is  surrounded  and  only  slightly  involved 
by  the  disease;  in  the  other  instance  the  jaw  is  destroyed 
by  the  disease.  (See  Figs.  30,  31 ,  35.) 

In  the  upper  jaw  it  is  difficult  to  distinguish  between 


46 


TUMORS   OF   THE   JAWS 


the  periosteal  sarcoma  originating  in  the  antrum  and  a 
myelogenous  or  giant-cell  sarcoma  of  the  antrum  on  account 
of  the  extreme  thinness  of  the  bony  wall  concerned. 

The  periosteal  sarcoma  is  apt  to  be  fibrous  and  tough. 
The    central    giant-cell    growth    is    soft.     The    periosteal 


Fig.  30. — Periosteal  round-cell  sarcoma.  Note  the  situation  at  the  angle 
of  the  lower  jaw.  A,  Condyle;  B,  section  of  bone  of  body  of  jaw.  C-D,  indi- 
cates the  line  of  section  the  surfaces  of  which  are  shown  in  Fig.  31.  Patho- 
logic report  by  W.  F.  Whitney.  A  soft,  grayish,  lobulated,  homogeneous 
growth,  occupying  the  ascending  ramus  of  the  jaw  and  part  of  the  body, 
which  was  atrophied  and  in  one  place  entirely  destroyed  by  the  tumor 
growth.  Microscopic  examination  showed  large  round  cells  with  a  little 
fibrillated  and  cellular  substance  between  them,  with  spaces  hollowed  out  in 
the  tissues  rather  than  true  vessels,  for  the  passage  of  the  blood.  In  a  few 
places  the  cells  were  elongated  and  rather  united  in  bundles  (Warren 
Museum,  No.  9720). 

growth  often  has  ossifying  forms,  streaks  of  bony  spicules 
throughout  the  growth. 

The  periosteal  sarcoma  of  the  jaw  is  either  a  mixed 
tumor  or  a  spindle-  or  round-cell  growth. 


SARCOMA    OF    THE    JAWS 


47 


The  periosteal  sarcomata  are  often  relatively  benign 
if  of  the  mixed  variety.  The  periosteal  sarcomata  may  be 
most  malignant  if  of  the  round-  and  spindle-cell  type,  or 
if  of  the  melanosarcoma  type.  The  giant-cell  or  central 
growth  is  usually  benign,  but  it  may  be  locally  quite  malig- 
nant. 

When  the  periosteal  growth  bursts  through  its  bony 
capsule,  it  infiltrates  the  soft  parts. 


Fig.  31. — Cut  section  of  Fig.  30.  Periosteal  round-cell  sarcoma.  Ar- 
rows point  to  the  body  of  the  jaw  remaining.  Bone  destroyed  extensively  by 
the  growth.  Case  from  Massachusetts  General  Hospital  series  (Warren 
Museum,  Xo.  9720). 

Periosteal  growths  are  attached  to  the  bone  and  are 
not  very  movable.  They  have  rather  definite  boundaries, 
a  smooth  surface,  intact  skin.  The  consistence  is  variable. 
It  is  usually  softer  than  bone.  It  is  almost  painless. 

A  central  growth  forms  a  tumor  or  a  bulging  of  the  bone, 
painless  to  pressure,  which  simulates  at  first  a  tooth  cyst. 
Later  the  bone  on  palpation  over  the  tumor  crackles,  and 
then  the  growth  breaks  through  the  thin  crackling  shell  of 
bone  and  an  ulcer  is  formed. 


48 


TUMORS   OF   THE   JAWS 


Mixed   Sarcoma. — If   these   periosteal   sarcomata   are 
associated  with  the  formation  of  cartilage,  the  term  chondro- 


Fig.  32. — Central  giant-cell  sarcoma  of  the  symphysis  of  the  lower  jaw. 
Anterior  view.  Note  the  tumor  and  the  displaced  teeth  (Warren  Museum 
No.  St29). 


Fig.  33.— Central  giant-cell  sarcoma  of  the  symphysis  of  the  lower  jaw 
teriOT  view.     Note  growth  within  the  expanded  and  thinned  bony  wall  of 
the  jaw— rare  situation  (Warren  Museum,  No.  8429). 


SARCOMA    OF    THE    JAWS 


49 


sarcoma  is  applicable.     The  chondrosarcoma  occurs  in  the 
upper  jaw  more  frequently  than  in  the  lower  jaw. 


Fig.  34. — Giant-cell  sarcoma  of  the  lower  jaw  of  a  child  six  years  old. 
A  central  growth  in  front  of  the  molar  teeth  extending  to  the  surface.  Out- 
side view  (Warren  Museum,  No.  8426). 


Fig.  35. — Inside  view  of  Fig.  34.  Note  the  central  origin  of  the  giant-eel 
sarcoma  within  the  body  of  the  lower  jaw  in  front  of  the  molar  tooth:  A,  Sec- 
tion of  symphysis;  C,  incisor  tooth;  D,  carious  molar  tooth;  E,  inferior  intact 
surface  of  body  of  jaw;  X>  tumor  seen  through  destroyed  cortex.  Arrows 
point  to  growth  occupying  site  of  alveolar  border  (Warren  Museum,  No.  8426). 


The    term    osteosarcoma    is    properly    applied    to   those 
periosteal  sarcomata  in  both  the  upper  and  lower  jaws  in 
4 


50 


TUMORS   OF   THE   JAWS 


Fig.  36. — A  sarcoma  of  the  upper  jaw  starting  within  the  antrum,  filling  it, 
and  invading  the  hard  palate  (Warren  Museum,  No.  9999). 


Fig.  37. — Sarcoma  of  the  upper  jaw  filling  the  antrum;  section  of  specimen  in 
Fig.  36  (Warren  Museum,  No.  9999). 


PLATE  IV 


Ostoosarcoma  involving  the  lower  jaw  and  appearing  at  the  alveolar  border. 
Appearance  through  mouth  (from  Mikulicz). 


SARCOMA    OF    THE    JAWS  51 

which  ossification  has  taken  place.  These  tumors  are 
therefore  spoken  of  as  osteo-  or  osteoid  or  ossifying  sarcomata. 
Fibro-,  chondro-,  myxo-,  osteo-,  sarcomata,  as  the 
names  indicate,  define  periosteal  growths  composed  of  sarco- 
matous  tissue  with  large  amounts  of  fibrous,  cartilaginous, 
myxomatous,  or  bony  tissue  associated  with  them.  This 
group  of  mixed  tumors  is  the  least  malignant  of  the  sarco- 
mata. (See  Plates  I  and  II.) 


Fig.  38. — Periosteal  sarcoma  of  the  upper  jaw:  A,  Hard  palate;  B, 
tumor;  C,  incisor  teeth;  D,  nasal  cavity;  E,  antrum  (from  the  Leipsic  Sur- 
gical Clinic). 


When  these  mixed  tumors  recur  after  operation,  the 
recurrence  will  often  be  more  malignant  than  the  original 
growth,  and  there  will  be  less  of  the  fibrous  tissue  and  more 
of  the  sarcomatous  element  present. 

These  mixed  tumors  are  relatively  benign  and  stand  be- 
tween the  truly  benign  and  the  malignant  sarcomata.  The 
mixed  tumors  are  of  quite  common  occurrence.  They  have 
their  seat  in  the  body  of  the  jaw. 


52  TUMORS   OF   THE   JAWS 

The  round-cell  sarcoma  is  very  malignant.  It  occurs 
in  the  upper  jaw  most  often,  and  is  like  the  carcinoma  m 
its  virulence.  It  usually  starts  from  the  antrum. 


Fi     39 -Patient  aged  sixty.     Tumor  of  lower  jaw;    first  observed  ten 
months  ago,  on  inner  side  of  teeth.     Removed  by  caret  seven  month; 
Recurrence.    Photograph    of    alcohol   specimen.     Microscopically,  a  typic 
giant-cell  sarcoma  (Bloodgood). 


Fig.  40. — Another  view  of  tumor  shown  in  Fig.  39. 


Fig.  41. — Another  view  of  tumor  shown  in  Fig.  39. 

soft  in  consistence,  of  rapid  growth.     Upon  section  it  is 
firm  and  white  or  grayish-white  in  color.     It  is  occasionally 


SARCOMA    OF   THE    JAWS  53 

mistaken  for  cancer.  It  recurs  locally  early.  It  occurs 
most  often  in  the  antrum  of  Highmore,  and  therefore  is 
known  as  the  antrum  sarcoma. 

The  Part  of  the  Jaw  First  Attacked  by  Sarcoma.— 
In  the  upper  jaw  sarcoma  occupies  most  commonly  the  body 
and  alveolar  process.  The  hard  palate  and  frontal  process 


Fig.  42. — Medullary  giant-cell  sarcoma  of  lower  jaw,  showing  tumor 
surrounding  non-erupted  tooth.  White  male,  aged  ten  years;  tumor  three 
months.  Resected;  patient  remained  cured  three  years  (from  original, 
loaned  by  Joseph  C.  Bloodgood). 

are  least  often  involved.  In  the  lower  jaw  the  body  and 
alveolar  process  are  alike  involved.  The  periosteal  spindle- 
and  round-cell  sarcoma  more  often  starts  near  the  angle 
of  the  jaw  and  extends  toward  the  ramus  and  about  it. 
Epithelioma  invades  the  alveolar  process  most  commonly. 
The  less  malignant  periosteal  osteosarcoma  starts  on  the 


54 


TUMORS   OF   THE   JAWS 


body  of  the  lower  jaw  more  often  than  on  the  alveolar 
border  or  the  ramus. 


Fig.  43. 


Fig.  44. 

Figs.  43  and  44. — Giant-cell  sarcoma  involving  body  of  lower  jaw.  Pa- 
tient lias  remained  cured  three  years  since  operation.  Patient  of  Dr.  Lund, 
of  Boston.  Fig  43  shows  a  side  view  of  the  jaw;  Fig.  44  shows  a  view 
from  above  (from  originals,  loaned  by  Joseph  C.  Blooclgood). 

The  relative  frequency  of  the  occurrence  of  sar- 
coma among  men  and  women  is  seen  in  the  accompany- 


SARCOMA    OF    THE    JAWS 


55 


ing  table.     The    first    six    clinics   are  computed  excluding 
epulis. 


AUTHOR. 

CLINIC. 

YEAR. 

UPPER  OR 
LOWER. 

NUMBER 
OF  SAR- 
COMA 

CASES. 

H 

a 

WOMEN. 

1  .    Bayer 

Frag 

1874 

Both  jaws 

11 

4 

7 

2  .    Birnbaum 

Augusta  Hospital, 

1871-1887 

Both  jaws         22 

4      18 

Berlin 

3  .    Martens 

Gottingen 

1875-1899 

Upper                27 

14 

13 

4.    Stein 

Bergmann,  Berlin 

1890-1900 

Upper                34 

17 

17 

5  .    Behm 

Gottingen 

1875-1902 

Lower                 19 

9 

10 

6.    Schmidt 

Groifswald 

1885-1902 

Lower                 13 

7 

6 

Total  .  .  . 

126 

55 

71 

7  .    Batzaroff 

Zurich 

1881-1890 

33 

12 

21 

(Including  epulis  cases) 

A  Case  of  Giant-cell  Sarcoma  of  the  Lower  Jaw  to  the 
Left  of  the  Symphysis.  Curetage.  No  Recurrence.— 
A  boy  twelve  years  old  was  operated  upon  by  Balch  at  the 
Massachusetts  General  Hospital  clinic  for  a  small  giant- 
cell  sarcoma  of  the  left  lower  jaw,  situated  in  the  region  of 
the  incisor  and  canine  teeth.  An  incision  was  made  (see 
Figs.  45-48)  from  the  angle  of  the  mouth  obliquely  back- 
ward and  downward,  dividing  the  lip  and  cheek  exten- 
sively enough  to  expose  the  growth  thoroughly.  The  growth 
was  removed  from  the  bone  and  the  seat  of  the  growth  was 
thoroughly  cureted  and  cauterized  with  the  actual  cautery. 

Microscopic  report  made  by  Wm.  F.  Whitney  stated 
that  the  growth  removed  was  a  giant-cell  sarcoma. 

A  month  after  the  operation  a  small  bit  of  dead  bone 
was  removed  through  a  sinus  in  the  original  incision.  One 
year  following  this  operation  the  boy  reports  that  the  sinus 
closed  shortly  after  the  second  operation,  and  that  he  has 
gained  13  pounds  in  weight  and  feels  well. 


56 


TUMORS   OF   THE   JAWS 


Fig.  45. — Boy  twelve  years  old.  Giant-cell  sarcoma  of  the  left  lower  jaw. 
Removed  by  curetage  and  the  actual  cautery.  No  recurrence  one  year  later. 
Note  the  tumor  of  the  chin  at  the  site  of  the  growth  (Balch). 


Fig.  46.— Same  as  Fig.  45.  Giant-cell  sarcoma  of  the  lower  jaw,  to  the 
left  of  the  median  line.  This  case  very  properly  occupies  the  border-line 
between  an  epulis  and  a  sarcoma.  No  recurrence  after  removal  (Balch). 


Fig.  47. — X-ray  of  case  in  Fig.  45,  showing  that  the  bone  is  not  extensively 

involved  (Balch). 


V 


s 


Fig.  48. — Giant-cell  sarcoma  of  the  lower  jaw.     Case  after  operation.     (See 

Fig.    46.)     Note   line   of   incision   through    cheek    (Balch). 

57 


58  TUMORS   OF   THE   JAWS 

Examination  finds  that  the  boy  looks  well,  that  the  scar 
is  a  linear  one,  and  that  the  bone  at  the  base  of  the  growth 
is  smooth  and  covered  with  mucous  membrane.  There 
are  no  glands  in  the  neck. 

The  limited  operation  performed  in  this  case  was  indi- 
cated because  of  the  situation  of  the  growth,  its  character, 
and  the  slight  involvement  of  the  ramus  of  the  jaw. 


In  the  Massachusetts  General  Hospital  series  of  cases 
analyzed  here,  including  the  epulis  cases,  there  are  about  an 
equal  number  of  male  and  female  patients.  Omitting 
the  epulis  cases,  there  are  about  one-third  more  male  cases 
of  sarcoma  than  there  are  female  cases.  One  observer 
thinks  that  males  are  afflicted  with  sarcoma  about  three 
times  as  often  as  females.  Nelaton  says  that  the  giant- 
cell  sarcoma  occurs  equally  often  in  the  two  sexes.  Females 
are  more  often  affected  with  sarcomatous  epulis  than  are 
males. 

The  etiologic  importance  of  a  single  isolated  trauma 
in  connection  with  sarcoma  is  more  nearly  settled  than  has 
been  generally  supposed.  There  is  some  evidence  offered 
by  good  observers  that  a  blow,  acute  trauma,  in  distinction 
from  chronic  trauma,  such  as  the  continuous  irritation  of  a 
tooth  on  the  cheek,  is  a  determining  factor  in  the  appear- 
ance of  sarcoma  in  one  point  in  the  bony  skeleton  rather 
than  at  some  other  point. 

Coley,  in  his  paper  upon  "Injury  as  a  Causative  Factor 
in  Carcinoma,"  presents  evidence  which  tends  to  substan- 
tiate the  claim  that  local  trauma  of  any  kind  is  the  direct 
exciting  cause  of  certain  malignant  tumors.  In  a  series  of 
970  cases  of  sarcoma  a  definite  traumatic  historv  was 


SARCOMA    OF   THE    JAWS 


59 


Fig.  49. 


Fig.  50. 

Figs.  49  and  50. — Medullary  giant-cell  sarcoma  beginning  centrally  in 
the  symphysis.  Age,  twenty-one.  Tumor  ten  months'  duration.  Patient 
has  remained  cured  nine  years  (Bloodgood:  Halsted's  clinic). 


60  TUMORS   OF   THE   JAWS 

obtained  in  225  cases,  that  is,  in  23  per  cent,  of  the  cases. 
The  tumor  developed  in  this  23  per  cent,  within  the  first 
month  after  the  injury  in  52  per  cent  of  the  225  cases. 
Certainly  there  is  a  basis  for  the  idea  of  an  "acute  traumatic 
malignancy." 

One  serious  objection  which  has  been  raised  to  the 
acceptance  of  the  importance  of  trauma  as  an  etiologic 
factor  in  the  production  of  sarcoma  has  been  that  no  examin- 
ation has  been  recorded  accurately  of  the  part  involved 
in  the  disease  previous  to  the  receipt  of  the  trauma.  Coley 
in  his  paper  records  two  cases  of  importance  in  this  con- 
nection. One  case  was  that  of  a  fractured  humerus  in  a 
man  in  perfect  health.  An  x-ray  photograph  was  taken 
immediately  after  the  fracture,  which  showed  normal 
bone.  Another  x-ray  was  taken  a  few  weeks  later  showing 
a  typical  sarcomatous  growth,  proved  by  microscopic  ex- 
amination. A  second  case  is  reported  by  Coley  in  which  in 
the  wound  of  an  inguinal  hernia  operation,  four  weeks  sub- 
sequently a  rapidly  growing  round-cell  sarcoma  developed. 

It  would  seem,  therefore,  that  evidence  is  accumulating 
to  establish  upon  a  scientific  basis  the  theory  of  the  etio- 
logic importance  of  trauma  in  the  causation  of  sarcoma. 
How  the  trauma  acts,  of  course,  has  not  yet  been  demon- 
strated. As  Coley  says,  fully  to  explain  the  nature  of  this 
relation  between  the  tumor  and  trauma  is  quite  another 
problem  than  to  prove  that  the  relationship  exists. 


A  Case  of  Giant-cell  Sarcoma  of  the  Lower  Jaw 
Following  Trauma.— Centrally  located.  Resection.  Nine 
years  subsequently  perfect  health.  (Massachusetts  General 
Hospital  Series,  vol.  383,  p.  255.  Service  of  H.  H.  A. 


SARCOMA    OF   THE    JAWS  61 

Beach.) — W.  C.,  a  boy,  thirteen  years  old.  A  year  and  a 
half  previous  to  operation  he  received  a  kick  in  the  chin 
while  playing  foot-ball.  A  swelling  appeared  immediately 
after,  and  in  three  weeks  had  attained  its  present  size.  At 
no  time  has  there  been  pain. 

Examination  finds  to  the  right  of  the  symphysis  of  the 
lower  jaw  a  mass  the  size  of  a  small  egg,  extending  from  the 
first  molar  on  the  right  side  to  the  first  bicuspid  on  the  left ; 


Fig;.  51. — Giant-cell  sarcoma  Fig.  52. — Giant-cell  sarcoma  of  lower 
of  the  lower  jaw  at  symphysis.  jaw.  Lateral  view.  Note  that  the  swell- 
Anterior  view.  Before  operation  ing  is  more  to  the  right  of  the  median  line 
(Massachusetts  General  Hospital  (Massachusetts  General  Hospital  series). 

series) . 

this  tumor  is  soft  and  fluctuating  and  contains  in  places 
what  feels  like  a  shell  of  bone.  The  surface  of  the  tumor  is 
purple  in  color,  is  covered  with  large  veins,  and  projects 
inside  as  well  as  outside  the  alveolar  margin.  A  bit  re- 
moved is  proved  by  microscopic  examination  to  be  a  giant- 
cell  sarcoma.  The  whole  symphysis,  with  a  portion  of 
the  body  of  the  jaw  upon  either  side  of  the  growth,  was 
removed  at  operation. 


62 


TUMORS    OF    THE    JAWS 


Pathologic  report  by  J.  H.  Wright  and  W.  F.  Whitney: 
Giant-cell  sarcoma.  A  portion  of  the  lower  jaw,  including 
the  symphysis,  covering  8  or  9  cm.  in  extent.  On  the  right 
it  was  swollen  to  a  tumor  about  3  inches  in  its  greatest 
diameter,  and  covered  on  the  surface  with  a  thin  shell  of 
bone.  The  tumor  occupied  the  center  of  the  bone.  On 
section  it  was  soft,  with  a  reddish-gray,  uniform  surface. 


Fig.  53. — Case  of  giant-cell  sar- 
coma of  lower  jaw.  Appearance  of  chin 
following  operation.  Note  receding  chin 
(Massachusetts  General  Hospital 
series) . 


Fig.  54. — Case  of  giant-cell 
sarcoma  of  lowrer  jaw  (Massachu- 
setts General  Hospital  series). 


Microscopic  examination  showed  it  to  be  composed  of 
small  spindle-  and  round-cells  in  elongated  bundles,  among 
which  were  large  nucleated  bodies.  The  blood-supply 
was  in  vascular  spaces  without  distinct  walls. 

Nine  years  later  there  was  no  recurrence  of  the  disease. 
The  illustrations  (Figs.  51  and  52)  show  the  appearance  of 
the  boy's  face.  This  case  was  reported  in  the  "  Boston 
Medical  and  Surgical  Journal,"  1902. 


SARCOMA    OF    THE    JAWS 


63 


The  question  arises  in  a  case  of  giant-cell  sarcoma  of 
the  jaw  seated  as  this  was,  at  the  symphysis:  Should  a 
resection  or  a  partial  operation  be  done?  At  the  time  that 
this  resection  was  done  the  success  attending  curetage  in 
giant-cell  sarcoma  was  not  recognized.  Resection  seemed 
the  wise  procedure.  To-day  in  a  similar  case  it  would 
seem  wise  to  remove  all  the  growth  by  curetage,  and,  if 


Fig.  55. — Case  of  giant-cell  sar- 
coma ;  x-ray  taken  previous  to  opera- 
tion. Note  the  thin  shell  of  bone  (B) 
surrounding  the  soft  central  growth 
at  the  symphysis  of  the  lower  jaw. 
"A,"  incisor  teeth  of  upper  jaw. 


Fig.  56. — Case  of  giant-cell  sar- 
coma. .X-ray  taken  after  operation. 
Note  the  absence  of  the  symphysis  of 
the  lower  jaw  and  also  an  absence  of 
considerable  of  the  horizontal  ramus 
of  the  jaw.  "A,"  incisor  teeth  of 
upper  jaw. 


sufficient  shell  of  bone  remained  for  support  to  the  jaw, 
resection  would  be  unnecessary. 

There  also  arises  the  very  pertinent  question:  May 
not  the  deformity  following  resection  of  the  symphysis  be 
at  least  partially  corrected  by  some  form  of  prosthetic 
apparatus?  There  is  no  doubt  but  that  an  immediate 
prosthesis  will  avoid  the  approximation  of  the  proximal  ends 


64  TUMORS   OF   THE   JAWS 

of  the  divided  rami  of  the  jaw.     The  width  of  the  chin  can 
be  preserved.     (See  chapter  on  Prosthesis.) 

The  case  described  (Figs.  51-56),  of  the  Massachusetts 
General  Hospital  series,  illustrated  the  close  relationship 
in  time  frequently  met  with  between  trauma  and  the 
discovery  of  a  swelling. 


There  are  benign  lesions  following  trauma  to  muscle 
and  bone.  The  organized  hematoma,  the  different  forms  of 
myositis,  especially  the  ossifying  myositis,  and  the  tumor 


Fig.  57.— Giant-cell  sarcoma  (central  myeloma).      Woman  thirty-eight  years 
old.    Tumor  of  the  lower  jaw  present  for  four  years  (Dudley,  Manila,  P.  I.) . 

of  the  rectus  abdominis  muscle  following  labor  are  instances 
of  traumatic  lesions  of  muscles.  In  bones  the  ossifying  peri- 
ostitis which  follows  trauma  is  familiar.  Tuberculous  and 
pyogenic  osteomyelitis  may  be  secondary  to  a  simple  trau- 
matic lesion.  The  syphilitic  gumma  as  an  ossifying  periostitis 
may  be  localized  by  trauma. 


SARCOMA    OF   THE    JAWS 


65 


The  sarcoma  may  not  develop  immediately  following 
trauma,  but  after  a  varying  period  of  time  has  elapsed. 
Coley  found  that  the  tumor  appeared  in  117  cases  within 
one  month  after  the  injury.  Bloodgood  has  emphasized 
the  importance  of  the  practitioner  being  careful  to  bear 
constantly  in  mind  the  possible  late  effects  of  trauma,  and 
I  may  add  no  matter  how  trivial  at  the  time  the  trauma 
may  seem  to  have  been. 


Fig.  58. — Periosteal  osteosarcoma  of  the  lower  jaw — view  in  transverse 
section:  X,  Arrow  points  to  the  bone  lying  intact  within  the  sarcoma;  A, 
the  articular  process  of  lower  jaw.  A  cystic  cavity,  3  cm.  wide,  occupies  the 
center  of  the  tumor  (Warren  Museum,  No.  9582). 


Melanosarcoma  occurs  most  commonly  in  the  upper 
jaw  and  in  the  hard  palate.  Of  the  19  cases  in  literature, 
only  2  occurred  in  the  lower  jaw.  These  latter  were  reported 
by  Luther  and  Levi. 

Melanosarcoma  is  extremely  malignant,  ulcerates  often, 
grows  rapidly,  and  causes  metastases.  Glands  are  involved 
in  almost  all  cases. 


Fig.  59. — Case  "Loris."    Note  tumor  of  the  neck  in  the  line  of  the  cicatrix 
of  the  original  operation.     This  tumor  was  an  enlarged  sarcomatous  gland. 
See   text.     Massachusetts  General  Hospital  series.) 


Fig.  60.— Case  "Lori.- 


-X"-ray  of  sarcoma  of    lower  jaw   (Massachusetts 
General   Hospital  series). 
66 


SARCOMA    OF    THE    JAWS  67 

Of  the  19  cases,  15  had  died  or  were  dying,  2  could  not 
be  found,  and  1  only  was  well  four  months  after  operation 
(Volkmann's  case). 

The  recurrence  of  a  melanosarcoma  may  or  may  not 
contain  pigment. 


Case  of  Sarcoma  of  the  Lower  Jaw  near  the  Angle; 
Resection. — Case  of  "Loris."  Massachusetts  General  Hos- 
pital series.  A  man,  thirty  years  old.  For  nine  months 
he  has  had  a  lump  underneath  the  left  lower  jaw.  The 
tumor  was  as  large  as  a  lemon.  This  has  been  sore  and 
tender.  After  his  teeth  were  removed  the  soreness  dis- 
appeared. The  tumor  is  hard  and  firm  and  is  attached  to 
the  jaw.  The  tumor  is  not  tender. 

One  half  the  jaw  with  the  tumor  was  removed  by  J.  C. 
Warren.  The  pathologic  report  made  by  Wm.  F.  Whitney 
was  a  round-cell  sarcoma. 

One  year  later  a  gland  was  removed  (see  Fig.  59)  from 
the  neck.  Six  months  later  there  was  evident  recurrence 
in  the  neck  and  region  of  the  ear.  It  was  then  thought 
to  be  inoperable. 


(B)     SARCOMA  OF  THE  UPPER  JAW 

Symptoms. — 1.  The  Early  Period. — The  symptoms  de- 
pend somewhat  upon  the  variety  of  sarcoma,  its  situation, 
and  the  age  of  the  patient. 

In  this  early  period,  which  includes  the  latent  time 
when  the  growth  is  not  visible  to  surgeon  or  patient,  the 
symptoms  are  largely  functional  difficulties.  A  just  appre- 
ciation of  these  early  functional  disturbances  will  secure 


68  TUMORS    OF   THE   JAWS 

these  cases  for  surgical  treatment  at  a  far  earlier  period  than 
at  present. 

The  patient  first  seeks  advice,  perhaps,  on  account  of 
trouble  with  his  teeth.  A  neuralgia,  referred  to  the  teeth,  is 
annoying.  These  slight  neuralgias  are  most  noticed  perhaps 
in  rather  delicate  individuals.  A  robust  individual  may 
think  less  of  these  premonitory  neuralgic  flashes.  The 
dentist,  upon  examination,  finds  sound  teeth,  uses  a  counter- 
irritant  to  the  gums,  and,  if  the  pain  persists,  later  extracts 
a  few  teeth.  Thus  the  pain  may  be  relieved  temporarily. 
The  roots  of  these  teeth  may  reveal  a  bit  of  tumor  tissue, 
or  an  attached  alveolar  wall  may  tell  the  tale  to  an  obser- 
vant dentist. 

The  teeth  may  become  loosened  by  the  growth.  The 
alveolar  process  and  gums  become  swollen  after  the  teeth 
are  removed,  of  a  blue  color,  and  perhaps  bleed  easily. 

Often  at  this  time  the  dentist  thinks  only  of  a  perios- 
titis of  the  bone — an  inflammatory  process  rare  in  the 
absence  of  carious  teeth.  He  should  suspect  a  malignant 
process.  Careful  examination  should  be  made  to  deter- 
mine the  exact  occasion  for  the  persistent  neuralgia,  the 
loosened  teeth,  the  spongy,  swollen,  and  bleeding  gum. 

Other  cases,  starting  in  the  antrum,  complain  of  pain  in 
the  cheek,  a  foul  discharge  from  one  nostril,  even  a  slight 
fullness  of  the  roof  of  the  mouth  on  one  side,  a  bulging  of  the 
cheek  with  edema  of  the  same,  a  numbness  of  the  upper 
lip,  cheek,  and  side  of  the  nose,  a  swelling  of  the  gum  in 
the  region  of  the  canine  teeth,  possibly  tenderness  to  pres- 
sure in  this  same  anteriorly  swollen  region,  and  a  swelling 
of  the  lower  turbinate.  The  symptoms  suggest  strongly 
an  inflammation  and  empyema  of  the  antrum.  Trans- 


SARCOMA    OF    THE    JAWS 


69 


illumination  of  the  cheek  may  be  practised.  If  pus  or  a 
solid  mass  occupies  the  antrum,  the  characteristic  dark 
area  as  compared  with  the  x-ray  appearances  of  the  well 
antrum  will  be  present.  In  the  absence  of  caries  of  the 
teeth,  empyema  of  the  antrum  must  not  be  diagnosed 
until  it  is  conclusively  demonstrated  to  be  present.  Repeated 
nasal  hemorrhages  that  do  not  yield  to  treatment  suggest 
sarcoma. 


A     Case    of    Lymphangiosarcoma    of    the    Jaw.— 

"Green."  Massachusetts  General  Hospital  series.  (See  Figs 
61  and  62.)  A  colored  man,  fifty-five  years  old,  for  nine 
years  has  had  trouble  with  the  lower  left  half  of  his  jaw. 


Fig.  61. — Lymphangiosarcoma.     Removed.     Recovery  (Massachusetts  Gen- 
eral Hospital  series.     H.  H.  A.  Beach). 


Since  the  removal  of  a  tooth  nine  years  ago  there  has  been 
a  lump  present  which  has  caused  little  local  disturbance, 
but  has  steadily  increased  in  size.  (See  Fig.  61.)  The  jaw 
was  removed  with  the  tumor,  which  was  found  encapsu- 


70  TUMORS    OF    THE    JAWS 

lated.  The  patient  made  an  excellent  recovery  and  was 
alive  and  well  six  years  subsequently.  The  tumor  was  a 
cystic  lymphangiosarcoma.  The  tumor  tissue  was  exam- 


Fig.  62. — Lymphangiosarcoma.  Removed.  Recovery.  Note  the  large 
ulcerating  mass  and  the  projection  of  the  tumor  into  the  floor  of  the  mouth 
(same  as  Fig.  61)  (Massachusetts  General  Hospital  series). 


ined  by  both  W.  F.  Whitney  and  J.  H.  Wright,  of 
the  Pathological  Laboratory  of  the  Massachusetts  General 
Hospital. 


Again,  the  patient  may  present  the  signs  of  a  nasal 
polyp,  the  polyp  being  merely  symptomatic  of  the  malig- 
nant disease.  The  patient  has  difficulty  in  breathing 
through  one  nostril,  the  voice  is  nasal,  and  he  snores  while 
sleeping.  A  mucopurulent  discharge  streaked  with  blood 
appears  from  the  affected  nostril.  Epistaxis  is  not  uncom- 


SARCOMA    OF    THE    JAWS  71 

mon.  There  may  be  slight  deafness  due  to  the  involve- 
ment of  the  pharyngeal  end  of  the  Eustachian  tube.  Re- 
moval of  the  polyp  affords  an  opportunity  to  make  a  micro- 
scopic diagnosis.  All  polyps  from  the  nose  should  be  care- 
fully examined  microscopically,  particularly  at  the  point 
of  attachment.  Especially  is  this  important  in  cases  of 
recurrent  polyps. 

If  in  the  presence  of  these  preliminary  suggestions  of 
malignancy  no  radical  osteoplastic  procedure  is  initiated 
for  the  removal  of  the  beginning  growth,  then  the  more 
evident  signs  of  sarcoma  will  become  apparent. 

In  still  other  instances  of  the  disease  the  beginning  is 
marked  by  infraorbital  neuralgia  or  a  projection  of  the 
eyeball  outward  and  upward  or  a  swelling  of  the  eyelids  or 
a  chemosis  and  a  diplopia. 

Certain  cases  seem  to  have  so  short  an  initial  period 
that  the  disease  jumps  to  a  fully  established  condition,  even 
without  premonitory  signs.  This,  of  course,  occurs  in  the 
very  rapidly  growing  and  fulminating  varieties  of  sarcoma. 

2.  Symptoms  of  the  Well-established  Period. — If  the  disease 
begins  in  the  alveolar  process  of  the  jaw,  it  may  simulate 
an  epulis.  The  growth,  however,  does  not  remain  superficial ; 
it  invades  the  anterior  wall  of  the  antrum  and  finally  may 
push  its  way  into  the  nose.  The  nose  being  closed  by  the 
growth,  the  patient  breathes  through  the  mouth;  the  tongue 
becomes  coated  and  dry.  Sleep  is  interrupted.  Food  col- 
lecting between  the  gums  and  cheeks  decomposes,  and  foul 
discharges  appear  in  the  mouth.  Deglutition  is  difficult. 
Smell  may  be  destroyed  in  whole  or  in  part.  Hearing  may 
be  affected.  There  may  be  roaring  in  the  ears,  which  may 
keep  the  individual  awake. 


72  TUMORS    OF    THE    JAWS 

All  degrees  of  tenderness  of  the  eye  appear.  Epiphora 
exists.  Conjunctivitis  follows.  Diplopia  may  be  present. 
Pain  may  not  be  very  marked  in  this  period.  A  dull  aching 
or  heavy  disagreeable  sensation  may  be  all  the  discomfort 
which  exists  in  the  diseased  part.  Crises  of  infraorbital 
or  auricular  pain  may  exist  during  this  period. 

The  cheek  may  be  swollen  and  edematous.  The  skin 
usually  is  normal  in  appearance;  it  may  be  ulcerated. 
Ulceration,  however,  is  more  characteristic  of  carcinoma 
than  of  sarcoma.  There  may  be  a  certain  amount  of  exoph- 
thalmos. 

The  swelling  beneath — that  is,  under  the  lip — is  rounded, 
smooth,  and  often  lobulated.  The  hard  palate  is  swollen 
and  irregular — knobby  in  appearance.  The  nose  is  obstructed 
on  the  affected  side.  The  obstructing  mass  bleeds  easily. 

The  tumor  is  closely  adherent  to  the  bone.  It  is  not  so 
closely  adherent  to  the  soft  parts.  The  tumor  feels  firm, 
although  the  surface  is  variable,  i.  e.,  it  is  springy,  almost 
fluctuating  in  parts.  There  is  often  a  bogginess  which  is 
rather  characteristic  of  sarcoma  in  this  situation.  Occa- 
sionally, too,  there  are  hard  places  in  the  tumor  surface. 

Glandular  enlargement  is  sometimes  found  at  this  stage 
in  the  submaxillary  region,  and  is  due  to  secondary  inflam- 
matory conditions  present. 

The  general  health  now  begins  to  be  affected.  There  is 
loss  of  flesh,  of  appetite,  and  of  color.  There  is  a  slight 
fever  and  some  headache.  A  malignant  cachexia  begins 
to  make  its  appearance. 

3.  Symptoms  of  the  Late  Period. — The  growth  of  the 
sarcoma  is  at  its  height.  The  cutaneous  covering  of  the 
growth  becomes  red,  inflamed,  and  ulcerated,  and  the 


SARCOMA    OF   THE   JAWS  73 

sarcomatous  mass  appears  through  the  ulcerated  opening 
in  the  soft  parts.  The  nasal  septum  is  destroyed.  It  is 
not  uncommon  to  see  masses  of  disease  growing  out  from 
the  nostrils.  The  palate  may  be  ulcerated  through.  The 
lymphatic  enlargement  becomes  sarcomatous.  The  fever 
is  constant.  All  the  disturbances  of  function  of  the  region 
become  exaggerated  and  very  marked.  Deglutition  and 
respiration  become  almost  impossible.  Emaciation  is  ex- 
treme and  the  patient  soon  dies. 

Summary  of  Clinical  Picture  of  Sarcoma  of  the 
Upper  Jaw. — There  are  certain  features  of  the  early  stages 
of  this  disease  that  it  is  important  to  remember.  Sarcoma 
does  not  always  begin  to  trouble  individuals  in  the  same 
way.  There  are  different  initial  symptoms  as  well  as 
different  clinical  courses. 

The  characteristic  signs  of  sarcoma  of  the  upper  jaw  are 
as  follows :  A  sore  spot  on  the  cheek;  a  swelling  or  lump  with 
subsequent  apparent  necrosis  of  bone ;  a  loosening  of  teeth ; 
the  alveolar  margin  of  the  jaw  sore,  this  ulceration  extend- 
ing to  the  roof  of  the  mouth  under  "careful  watching"; 
a  lump  in  the  right  nostril,  plugging  it;  a  persistent,  foul 
discharge  from  the  nostril ;  intermittent  bleeding  from  the 
nose;  a  numbness  of  the  upper  lip  and  cheek;  " necrosis  of 
the  jaw"  for  many  months — these  are  a  few  of  the  early 
and  later  manifestations  of  this  disease  of  the  upper  jaw. 

The  hard  palate  becomes  flattened,  and  later  bulges. 
The  orbital  plate  rises  upward,  causing  a  disturbing  double 
vision.  Double  vision  may  be  the  only  early  symptom  of 
sarcoma  of  the  antrum. 

Chronic  edema  of  the  eyelids  is  not  rare.  An  enlarge- 
ment of  the  superficial  veins  of  the  face  is  sometimes  seen 


74  TUMORS   OF   THE   JAWS 

in  early  sarcoma.  The  nasolacrimal  duct  being  obstructed, 
tears  will  course  over  the  cheek.  Edema  may  be  noted 
in  one-half  the  nasal  mucosa  before  it  is  apparent  in  the 
face.  Cases  are  at  times  treated  for  nasal  polyp  for  so 
long  a  time  that  the  disease  has  advanced  too  far  for  suc- 
cessful surgical  excision. 

Sarcoma  of  the  upper  jaw  (central),  of  the  antrum,  is 
often  complicated  with  empyema  of  the  antrum.  Mikulicz 
has  called  attention  to  this  fact.  Consequently  in  all 
empyemata  of  the  antrum  it  is  important  to  consider 
malignant  disease.  Bleeding  from  the  nose  is  earlier  in 
carcinoma  than  in  sarcoma. 

If  cases  of  sarcoma  are  left  untreated,  death  usually 
occurs  because  of  some  complicating  disease.  Metastases 
take  place  to  other  parts,  often  to  the  lungs  or  the  brain. 


A  Case  of  Periosteal  Sarcoma. — "McKerlick." 
Massachusetts  General  Hospital  series.  A  woman,  sixty 
years  old.  Twelve  years  previously  she  had  an  ulcerated 
tooth.  An  abscess  opened  upon  the  cheek  at  this  time  and 
a  discharging  sinus  persisted  for  a  long  period.  In  1876  a 
piece  of  necrotic  bone  was  removed  from  the  left  lower  jaw 
at  the  site  of  the  original  ulcerated  tooth.  In  1880  a  swelling 
appeared  upon  the  lower  left  jaw  about  the  size  of  an  Eng- 
lish walnut,  at  the  site  of  the  former  osteomyelitis.  After 
remaining  quiescent  for  three  years  it  grew  rapidly.  Dur- 
ing the  past  two  months  there  has  been  considerable  pain 
in  this  swelling.  At  present,  previous  to  operation,  there 
is  seen  a  rounded,  conical  tumor,  the  size  of  two  adult 
fists,  extending  from  the  angle  of  the  jaw  forward  to  the 
symphysis.  (See  Fig.  63.)  There  are  no  teeth  present  in 
either  jaw.  The  mucous  membrane  of  the  mouth  is  every- 


SARCOMA    OF   THE    JAWS 


75 


a  b 

Fig.  63. — a,  Osteosarcoma  (periosteal)  of  the  lower  jaw.  The  body  of  the 
jaw  was  involved,  rather  than  the  ramus.  b.  Appearance  soon  after  excision  of 
one-half  of  the  lower  jaw  for  periosteal  sarcoma  (Massachusetts  General  Hos- 
pital series). 


Fig.  64. — Same  as  Fig.  63.  Appearance  of  left  side  of  the  face  three  years 
after  removal  of  the  left  half  of  the  lower  jaw  for  periosteal  sarcoma.  No 
prosthetic  appliance  has  ever  been  used.  Note  the  sinking  in  of  the  region 
formerly  occupied  by  the  jaw,  especially  in  region  of  ascending  ramus  in 
front  of  and  below  ear  (Massachusetts  General  Hospital  series). 


76  TUMORS    OF    THE    JAWS 

where  intact.  The  skin  over  the  tumor  is  normal  in  appear- 
ance. The  Roentgen  ray  shows  a  bony  shell  inclosing  a 
tumor,  together  with  bony  trabeculse  extending  in  from  the 
surface  toward  the  jaw. 

In  1903  one  half  of  the  lower  jaw  was  removed.  The 
woman,  in  1906,  was  well  and  had  just  recovered  from  a 
hysterectomy  for  chronic  endometritis.  The  illustrations 
were  taken  in  1906.  (See  Figs.  64  and  65.) 


Fig.  65. — Appearance  of  face  three  years  after  removal  of  the  left  half  of 
the  lower  jaw  for  periosteal  sarcoma.  No  prosthetic  appliance  has  ever  been 
used  (Massachusetts  General  Hospital  series). 

The  microscopic  examination  made  by  W.  F.  Whitney 
of  the  tumor  removed  from  the  jaw  proved  it  to  be  osteo- 
sarcoma  of  periosteal  origin. 


A  Case  of  Sarcoma  of  the  Lower  Jaw. — Case  of 
"Kessel."  Massachusetts  General  Hospital  series.  (See 
Figs.  66  and  67.)  A  man  thirty-eight  years  old  had  a  sore 
upon  the  inside  of  the  right  cheek  for  some  eight  months. 


SARCOMA    OF    THE    JAWS 


77 


Fig.  66. — Sarcoma  of  lower  jaw.  Note  the  reddening  of  the  skin  over  the 
cheek  tumor;  the  glandular  enlargement  in  the  neck.  Inoperable  (Massa- 
chusetts General  Hospital  series). 


Fig.  67. — Sarcoma  of  lower  jaw.     Inoperable  (Massachusetts  General  Hos- 
pital series). 


78  TUMORS    OF    THE    JAWS 

For  four  months  the  whole  cheek,  as  seen  in  the  illustra- 
tions (Figs.  66  and  67),  has  been  swollen.  There  has  been 
little  or  no  real  pain,  but  considerable  local  discomfort. 
During  the  past  two  months  the  tumor  has  grown  rapidly. 
The  tumor  is  attached  to  and  involves  the  lower  jaw. 
The  swelling  seen  in  Fig.  66  has  appeared  recently  and  is 
a  lymphatic  enlargement.  The  skin  over  the  tumor  at  the 
darkest  part  of  the  swelling  (see  Fig.  66)  is  reddened.  The 
temperature  is  100°  F.  The  patient  was  discharged  from 
the  hospital  without  operative  treatment. 

Remarks:  The  evident  cachexia  (anemia);  the  rapid 
extension  of  the  disease  locally  and  into  the  lymphatics  of 
the  neck;  the  infiltration  of  the  alveolar  process — all  made 
it  seem  unwise  to  attempt  eradication  of  the  disease  by 
operation. 


Diagnosis. — A  suspicion  of  malignant  disease  in  the 
early  stages  may  be  entertained,  but  a  diagnosis  is  then 
most  difficult.  Cases  presenting  suspicious  signs  must  be 
scrutinized  with  very  great  care.  The  dentist  seeing  such 
cases  should  communicate  his  forebodings  of  ill  to  a  surgeon, 
in  order  that  the  responsibility  may  be  shared  and  definite 
conclusions  reached. 

Empyema  of  the  antrum  which  is  frank  and  characteristic 
will  hardly  be  mistaken  for  sarcoma.  If  a  supposed  empy- 
ema  of  the  antrum  develops  slowly  and  insidiously  without 
improvement  under  proper  treatment  for  empyema,  sarcoma 
should  be  suspected,  and  a  bit  of  tissue  should  be  removed 
for  microscopic  examination  before  an  exploratory  incision 
is  made. 

Nasal  polypi  normally  do  not  resemble  sarcoma.  If 
nasal  polypi  become  inflamed  and  are  red  and  swollen,  they 


SARCOMA    OF    THE    JAWS 


79 


then   may   simulate    sarcomatous   tissue    in   gross   appear- 
ance. 

Alveolar  periostitis  which  develops  almost  painlessly, 
accompanied  by  swelling  of  the  gums,  should  be  regarded 
with  suspicion,  and  especially  if  a  good  condition  of  the  teeth 
exists.  When  alveolar  periostitis  is  well  established,  the 
diagnosis  is  not  difficult. 


Fig.  68. — Sarcoma  of  parotid.  Note  that  the  swelling  lies  behind  the 
body  and  angle  of  the  jaw  and  extends  forward  only  secondarily  (Massachu- 
setts General  Hospital  series,  C.  B.  Porter). 

The  antral  cases,  the  nasal  cases,  those  involving  the 
palate,  all  present  characteristic  local  symptoms  already 
referred  to,  and  the  alveolar  cases,  which  are  often  cases 
of  epulis,  are  comparatively  easily  diagnosed.  The  multiple 
ulcerations,  whether  of  cheek  or  mouth  or  palate,  character- 
ized by  an  undermined  edge  through  which  the  tumor  mass 
protrudes  as  an  exuberant  growth,  are  very  characteristic. 


80  TUMORS    OF   THE   JAWS 

The  great  fetor,  the  ready  hemorrhage  upon  slight  trauma, 
extensive  glandular  involvement,  all  may  simulate  carcinoma. 
When  the  disease  has  advanced  so  far  that  it  is  confused 
with  carcinoma,  it  matters  little,  for  the  treatment  is  prac- 
tically similar  under  either  condition. 

Tumors  of  the  soft  parts  overlying  the  upper  jaw  must 
not  be  confused  with  sarcoma  of  the  jaw.     Tumors  of  the 


Fig.  69. — Enlarged  glands  of  neck.  Woman,  thirty-five  years  old.  Jaw 
uninvolved.  The  tumor  is  posterior  to  the  seat  of  a  jaw  tumor  (F.  W. 
Dudley,  Manila,  P.  I.). 

soft  parts  can  ordinarily  be  demonstrated  to  have  no  con- 
nection with  the  bone.  A  sarcoma  of  the  jaw  is  always  very 
intimately  connected  with  the  bone. 

The  odontomata,  unless  a  sarcomatous  element,  is  grafted 
upon  them,  are  of  rather  slow  growth.  They  are  found  in 
young  people  in  the  region  of  the  molar  teeth;  one  or  more 
teeth  may  be  lacking  from  the  jaw. 

Dental  cysts  will  hardly  be  confused.     They  grow  slowly 


SARCOMA    OF    THE    JAWS  81 

and  are  of  small  size,  and  present  the  parchment-like  crepi- 
tus. 

Osteomata  are  of  very  slow  growth,  are  extremely  hard, 
and  are  smooth  and  rounded. 

Gummata  may  appear  on  the  palate,  but  early  ulcer- 
ation  and  their  association  with  other  apparent  syphilitic 
lesions  would  make  it  highly  improbable  that  there  could 
be  much  difficulty  in  diagnosis. 


Fig.  70. — ^Enlarged  glands  of  neck.  Woman,  thirty-five  years  old.  Note 
temporal  region  and  front  of  ear  not  involved.  Jaw  uninvolved  (F.  W. 
Dudley,  Manila,  P.  I.). 

Carcinoma  usually  occurs  after  fifty  years  of  age.  The 
growth  of  the  disease  is  rapid  and  progressive.  The  glan- 
dular involvement  is  early  in  the  submaxillary  region.  The 
general  health  is  very  early  affected.  Ulceration  of  the 
carcinomatous  tumor  occurs  early.  Carcinomatous  ulcers 
are  continuous  at  their  edges  with  the  mass  of  the  growth. 
The  margin  of  the  ulcer  is  not  undermined. 
8 


82 


TUMORS    OF    THE    JAWS 


Several  cases  of  sarcoma  have  been  supposed  to  be 
syphilitic  lesions.  Prolonged  treatment  of  these  cases 
with  iodid  of  potassium  has  been  followed,  of  course,  with 
little  or  no  effect.  Treatment  of  such  suspected  syphilitic 
cases  with  mercury  has  often  confused  the  clinical  picture 


Fig.  71. —  Sarcoma  of  parotid. 
Ulcerating.  Note  situation  of  swelling 
at  side  of  face.  If  a  growth  involves 
the  jaw  and  ascending  ramus,  it  extends 
up  more  into  temporal  region  and  more 
anteriorly  along  the  body  of  the  jaw 
(F.  W.  Dudley,  Manila,  P.  I.). 


Fig.  72. — Sarcoma  of  parotid. 
Ulcerating.  Note  situation  of  swell- 
ing at  side  of  face.  Jaw  uninvolved 
(F.  W.  Dudley,  Manila,  P.  I  ). 


because  of  the  salivation  and  offensive   breath   resulting, 
suggesting,  from  the  picture,  carcinoma. 

Prognosis. — This  depends  upon  the  histologic  character 
of  the  growth,  the  age  of  the  patient,  the  time  elapsed  from 
the  detection  of  the  growth  until  operation,  and  the  nature 
of  the  operation. 


83 

In  general  it  may  be  said  that,  as  in  other  situations, 
the  giant-cell  sarcoma  is  of  slow  growth,  without  glandular 
enlargement,  rarely  recurs  after  operation,  and  rarely  gives 
rise  to  metastases. 

On  the  other  hand,  the  round-cell  and  spindle-cell 
sarcomata  are  very  malignant.  Sometimes  an  ulceration 
may  take  place  directly  through  the  cheek,  although  this 
is  more  characteristic  of  carcinoma. 

Mortality  Due  to  the  Operation. — The  exact  pro- 
cedure carried  out  at  the  time  of  the  operation,  the  perso- 
nality of  the  individual  operator,  the  final  diagnosis  of  the 
growth,  the  physical  condition  of  the  patient,  the  duration 
of  the  growth  previous  to  operation — all  these  facts  should 
be  known  concerning  each  case  in  any  series  where  mor- 
tality figures  are  being  studied.  Mortality  figures  are  of 
little  value  unless  accompanied  by  all  these  facts. 

Comisso  has  compiled  the  table  (see  p.  283)  from 
the  literature  of  resections  of  the  upper  jaw.  The  death- 
rate  following  total  resection  in  recent  times  has  dropped 
only  about  4.5  per  cent.,  as  compared  with  resections  done 
previous  to  1875. 

Bryant's  collected  cases  would  be  of  greater  value  if 
the>  details  of  the  cases  were  mentioned  and  the  operators' 
names  given.  He  collected  114  cases  of  upper  jaw 
malignant  disease  in  which  one  or  both  (7  cases)  jaws  were 
removed,  with  a  mortality  of  13  per  cent. 

Butlin  collects  from  three  hospitals  in  London, — St. 
Bartholomew's,  St.  Thomas',  and  University  Hospital,— 
between  the  years  1886-1897,  127  cases  of  upper  jaw  tumors 
operated  upon,  with  16  deaths — practically  13  per  cent. 
mortality. 


84  TUMORS    OF   THE   JAWS 

Martens  reports  from  Konig's  clinic  in  Gottingen  74 
cases  with  22  deaths,  or  30  per  cent,  mortality. 

The  Massachusetts  General  Hospital  clinic  presents, 
from  1898  to  1906, — a  period  of  eight  years, — 11  cases 
of  sarcoma  of  the  upper  jaw,  with  one  death,  due  to  cerebral 
embolism — a  mortality  of  9  per  cent. 


A  Case  of  Giant-cell  Sarcoma  of  the  Upper  Jaw.— 

R.  E.,  a  woman  thirty-three  years  old,  married.     Service 
of  C.  B.  Porter,  Massachusetts  General  Hospital. 


Fig.  73. — Giant-cell  sarcoma  of  the  right  upper  jaw.     Xoto  the  tumor  of 
the  right  cheek  (Massachusetts  General  Hospital  series,  C.  B.  Porter). 


The  teeth  of  the  upper  jaw  were  unsound,  so  that  all 
roots  and  teeth  in  this  jaw  were  removed.  Six  years  ago  a 
false  set  was  fitted  and  worn.  One  year  ago  there  was 


SARCOMA    OF    THE    JAWS  85 

noticed  an  ulcer  upon  the  gum,  over  the  upper  jaw,  upon 
the  right  side.  The  development  of  this  ulcer  was  associ- 
ated with  a  swelling  of  the  right  cheek,  which  at  the  time  of 
operation  was  the  size  of  a  lemon.  This  swelling  is  not 
tender  or  painful;  the  surface  is  smooth.  The  feeling  of 
the  tumor  is  that  of  a  semisolid  body.  There  is  a  small 
ulceration  in  the  gum  of  the  upper  right  jaw.  There  is  no 


Fig.  74. — After  excision  of  the  right  upper  jaw  for  giant-cell  sarcoma  (Massa- 
chusetts General  Hospital  series). 


discharge  from  this  ulcer.  There  are  no  lymphatic  glands 
to  be  felt  in  the  neck.  The  right  nostril  is  occluded.  There 
is  an  egg-shell  crackle  upon  the  inside,  over  the  region 
of  the  hard  palate.  The  right  upper  jaw  was  excised. 

Pathologic  report  by  W.  F.  Whitney.  A  growth 
from  the  upper  jaw  projecting  forward  over  the  teeth  on 
the  right  side,  covered  by  a  thin,  papery  bone.  On  section, 
there  were  numerous  spaces  separated  by  bony  partitions, 
filled  with  a  homogeneous  reddish,  soft  substance,  which, 


86  TUMORS   OF   THE   JAWS 

upon  microscopic  examination,  showed  small  round-  and 
spindle-cells,  lying  among  which  were  numerous  larger, 
multinucleated  giant-cells.  Diagnosis:  Giant-cell  sarcoma. 
Present  condition:  Several  years  after  operation  the 
patient  is  in  good  health  and  has  no  trouble  with  the  jaw. 


The  mortality  of  the  operation  in  foreign  Continental 
clinics  will  be  seen  to  be  surprisingly  larger  than  that  in 
this  country.  Konig,  at  the  Gottingen  clinic,  as  reported 


Fig.  75. — After  excision  of  the  right  upper  jaw  for  giant-eel!  sarcoma.    No  pros- 
thesis used  (Massachusetts  General  Hospital  series). 

by  Martens,  had  a  mortality,  in  74  total  resections  of  the 
upper  jaw,  of  22  cases,  or  about  30  per  cent.  As  Martens 
has  pointed  out,  the  relatively  high  mortality  is  not  due  to 
lack  of  skill  in  early  operations,  for  the  mortality  is  as 
great  in  the  later  cases,  but  the  explanation  lies  in  the  fact 
of  far  more  radical  primary  procedures.  The  disease  is 


SARCOMA   OF   THE   JAWS  87 

tackled  harder — the  operations  generally  are  far  more 
extensive  than  those  done  in  this  country.  The  results  of 
thus  operating  more  radically  are  seen  in  the  ultimate  cures. 

Surgeons  in  this  country  have  been  content  with  a  low 
mortality:  they  have  been  concerned  in  getting  the  patient 
off  the  operating-table  alive,  and  have  in  the  past,  perhaps, 
sacrificed  completeness  of  operations  to  the  immediate 
safety  of  the  patient. 

This  is  not  the  proper  attitude  to  take  toward  malignant 
disease.  More  radical  measures  should  tie  employed  in 
these  cases  of  jaw  sarcoma.  These  remarks  apply  to 
sarcoma  of  both  upper  and  lower  jaws.  Patients  are 
simply  to  be  told  that  the  disease  is  desperately  malignant, 
and  that  desperate  and  most  radical  measures  are  to  be 
employed.  Tampering  with  a  growth  by  a  small  and  inade- 
quate operation  is  poor  surgery.  If  greater  chances  are 
taken  than  hitherto  in  these  desperate  cases,  the  death-rate 
may  be  a  little  higher,  but  the  cures  will  be  more  frequent. 

Causes  of  Death  after  Operation. — A  knowledge 
of  the  causes  of  death  immediately  following  operation  is 
of  very  considerable  practical  importance.  If  these  causes 
can  be  eliminated,  it  may  be  possible  to  diminish  the  oper- 
ative mortality. 

Rabe's  earlier  statistics  make  one  shudder  at  the  tre- 
mendous mortality  from  sepsis,  as  seen  in  erysipelas,  pyemia, 
etc.  Sepsis  has  practically  been  eliminated  as  a  cause  of 
death.  The  only  hold  which  sepsis  has  is  shown  in  the 
occasional  death  from  meningitis.  Martens  records  from 
the  Gottingen  clinic  three  deaths  from  purulent  meningitis. 
These  deaths  suggest  the  very  great  care  which  must  be 
exercised  in  dealing  with  the  accessory  sinuses  and  the  upper 


88  TUMORS   OF   THE   JAWS 

and  posterior  chambers  of  the  nose.  If  the  dura  is  to  be 
exposed,  it  must  be  only  after  extreme  cleanliness  of  the 
overlying  parts  has  been  secured.  The  parts  should  be 
protected  by  a  careful  occlusive  dressing.  (See  Operative 
Technic.) 

From  the  Massachusetts  General  Hospital  clinic  there 
were  no  deaths  from  sepsis. 

Hemorrhage  as  a  cause  of  death  is  a  small  factor  today 
as  compared  with  the  immediate  past.  The  elimination 
of  sepsis  has  done  away  with  secondary  hemorrhage.  The 
introduction  of  better  technic  has  (see  Operative  Technic) 
almost  eliminated  primary  hemorrhage — at  least,  any 
alarming  primary  hemorrhage. 

Rabe  had  112  deaths  in  his  list  of  upper  jaw  cases;  of 
these,  15  died  of  hemorrhage,  or  a  hemorrhage  mortality 
of  13  per  cent. 

Kiister  records  29  total  jaw  resections  with  2  deaths 
from  hemorrhage — a  mortality  of  6  per  cent. 

Bryant  thought  that  about  4  per  cent,  of  the  cases  he 
had  collected  had  died  of  primary  hemorrhage. 

Martens  reports  22  deaths  following  total  resections, 
with  only  one  death  from  hemorrhage — 4  per  cent,  mortal- 
ity. 

At  the  Massachusetts  General  Hospital  clinic  there  has 
been  no  death  from  hemorrhage. 


Case  of  Sarcoma  of  Upper  Jaw.  Repeated  Opera- 
tions.— In  the  case  of  Steele  (Fig.  76)  is  illustrated  a  very 
important  practical  point  in  the  treatment  of  the  less  malig- 
nant type  of  sarcomata.  The  patient  was  kept  under  very 


SARCOMA    OF    THE    JAWS 


89 


rigid  observation,  being  seen  every  two  or  three  months;  the 
opening  in  the  face,  exposing  the  deeper  parts,  the  posterior 
nares  and  the  pharynx,  was  not  closed  by  a  plastic  opera- 
tion, in  order  that  it  might  be  possible  thoroughly  to 
inspect  the  most  likely  seat  of  any  recurrent  disease. 

By  postponing  a  plastic  operation  it  was  comparatively 


Fig.  76. — Spindle-cell  sarcoma  of  the  right  upper  jaw.  Repeated  opera- 
tions for  small  local  recurrences.  After  seven  years,  death  (Massachusetts 
General  Hospital  series,  Steele). 

easy  to  detect,  at  an  early  period,  any  recurrent  nodule. 
The  patient  herself  was  able  intelligently  to  inspect  the 
seat  of  possible  recurrence,  and  several  times  she  reported 
a  suspicious-looking  spot  in  the  posterior  nares.  Not  only 
did  the  leaving  open  of  the  face  wound  enable  the  surgeon 


90 


TUMORS    OF    THE    JAWS 


and  patient  to  inspect  the  suspicious  area,  but  easj'  access 
was  made  possible  to  the  very  depths  of  the  wound. 

This  case  illustrates  the  value  of  repeated  operation 
upon  small  local  recurrences.  This  patient  was  operated 
upon  some  twenty  times  during  a  period  of  seven  years  or 


Fig.  77. — Spindle-cell  sarcoma  of  Fig.    78. — Spindle-cell    sarcoma 

right  upper  jaw  (Massachusetts  Gen-      of  right  upper  jaw.   Artificial  eye  and 
— i  Tj~,~:4.»i  — .-»„    cs^-i^  cheek  worn  by  patient  to   preserve 

facial  symmetry  (Massachusetts  Gen- 
eral Hospital  series). 


eral  Hospital  series,  Steele). 


more.  At  no  time  after  the  removal  of  the  eye  and  the 
clearing  out  of  the  orbit  was  any  one  operation  of  great  ex- 
tent. At  each  procedure  sound  tissue  was  apparently  divided, 
but  despite  this  fact  local  recurrences  subsequently  appeared. 


The  deaths  from  pneumonia  have  been  the  most  common 
form  of  death. 

Rabe  gives  20  deaths  from  this  cause  in  112  cases,  or 
16  per  cent. 


SARCOMA    OF   THE    JAWS  91 

Martens  records  22  deaths  as  a  total,  and  of  these,  16 
were  due  to  respiratory  troubles,  making  a  pneumonia 
mortality  of  72  per  cent.  This  is  perfectly  astounding. 

At  the  Massachusetts  General  Hospital  clinic,  in  the 
series  of  26  cases,  there  have  been  no  deaths  from  pneumonia. 

In  the  chapter  upon  Operative  Technic  will  be  dis- 
cussed the  possible  methods  of  eliminating  pneumonia  as 
a  cause  of  death. 

There  are  many  deaths  attributed  to  shock  and  exhaus- 
tion. These  are  most  probably  cases  in  which  hemorrhage 
has  been  the  contributing  factor  to  the  shock.  There  is 
no  great  shock  ordinarily  attending  a  properly  executed 
partial  or  complete  operation  upon  the  upper  or  lower  jaws. 

Martens'  series  of  deaths  is  interesting.  There  were  22 
deaths  following  total  resections  of  the  upper  jaw  for  sar- 
coma and  carcinoma.  Of  the  12  partial  resections,  only  one 
died.  Death  was  due  to  pneumonia  seven  days  after  oper- 
ation. Of  the  22  total  resection  deaths,  there  were  16  due 
to  respiratory  difficulties,  pneumonia,  bronchitis,  etc.,  and 
only  1  from  hemorrhage.  There  were  3  deaths  from  puru- 
lent meningitis.  There  was  1  death  from  sepsis  after  six 
days.  There  was  1  case  reported  dead  from  general  maras- 
mus, which  must  mean  from  cachexia  due  to  the  disease. 

Rabe  collected,  between  1827  and  1873,  a  series  of  606 
cases,  in  which  series  112  deaths  are  recorded.  One-fifth 
of  all  these  cases  died  of  sepsis.  Fifteen  died  of  hemorrhage. 
Twenty  died  of  pneumonia. 

Kiister  records  8  deaths  in  his  series.  Two  of  these 
deaths  were  from  hemorrhage,  and  4  were  from  pneumonia. 

One  death  was  from  exhaustion  and  1  was  from  corrosive 
poisoning. 


92  TUMORS   OF   THE   JAWS 

A  Case  of  Osteochondromyxosarcoma,  with  Re- 
moval of  the  Upper  Jaw  and  Formation  of  New  Hard 
Palate  (Massachusetts  General  Hospital  Series) .*- 
W.  H.  B.,  a  man  thirty  years  old,  was  sent  to  the  hospital 
by  Seabury  W.  Allen.  Twenty-two  years  ago  he  had  first 
noticed  a  slight  swelling  under  the  left  eye.  This  gradually 
increased,  until  he  presented  the  appearance  seen  in  the 
illustrations.  (See  Figs.  79,  80,  81,  82,  and  Plate  I.) 


Fig.  79. — Case  of  mixed  sarcoma  (Mixter). 

S.  J.  Mixter  removed  the  tumor,  leaving  the  two  eyes 
and  soft  palate  intact.  (See  Plate  II.)  He  subsequently 
formed  a  hard  palate  from  a  piece  of  bone  left  in  the  skin- 
flap  (antral  wall).  The  patient  made  a  good  recovery,  and 
was  alive  one  year  subsequently,  eating,  talking,  and  breath- 
ing without  difficulty,  gaining  in  weight,  and  from  being 
shut  in  his  room  apart  by  himself,  he  now  earns  his  living. 
This  patient  died  three  years  later  of  pneumonia. 

*S.  J.  Mixter:     Trans.  Am.  Surg.  Assoc.,  vol.  xxii,  p.  227,  1904. 


SARCOMA    OF    THE    JAWS 


93 


Fig.  80. — Case  of  mixed  sarcoma  (Mixter). 


Fig.  81. — Case  of  mixed  sarcoma  (Mixter). 


94  TUMORS   OF   THE    JAWS 

Partial  Operation  vs.  Total  Operation. — It  may  be 
wise,  in  certain  cases,  to  remove  the  disease  without  sacri- 
ficing much,  if  any,  of  the  maxilla  itself. 

In  the  long  bones  of  the  body  it  is  now  recognized  as 
sometimes  wise  to  remove  the  whole  of  a  giant-cell  sarcoma, 
leaving -the  bony  shaft.  The  statistics  of  Bloodgood  and 
others,  and  the  cases  from  the  Massachusetts  General 
Hospital  clinic,  demonstrate  that  in  very  carefully  selected 


Fig.  82. — Case  of  mixed  sarcoma  (Mixter). 

cases  of  giant-cell  sarcoma  of  the  long  bones,  this  course  is 
safe  and  wise. 

So  in  case  of  a  giant-cell  sarcoma  arising  from  the  center 
of  the  maxilla  removal  of  the  growth  with  the  preservation  of 
a  bridge  of  uninvolved  bone  is  the  best  procedure.  The 
maintenance  of  the  continuity  of  the  bone  secures  stability 
to  the  face,  and  offers  ample  support  for  proper  artificial 
teeth — a  great  desideratum. 


Case  of  osteo-ohomlro-myxo-sarcoma.     Result  after  operation  (Mixter). 


Case   of   osteo-chondro-myxo-sarcoma   after  recovery  from   the    operation 

(Mixter). 


SARCOMA    OF    THE    JAWS  95 

The  following  operations  from  the  Massachusetts  Gen- 
eral Hospital  clinic  serveto  illustrate  cases  in  which  a  partial 
operation  for  the  removal  of  malignant  jaw  tumors  was 
done.  Microscopic  examinations  were  made  in  each  case. 

Case  1  had  existed  four  months.  It  was  an  osteoid 
sarcoma.  The  patient  has  been  well  and  free  from  recur- 
rence for  five  years. 

Case  2  had  had  symptoms  of  trouble  with  the  jaw, 
simulating  necrosis  of  the  bone,  for  one  year  previous  to 
operation.  It  was  a  sarcoma;  the  type  of  cell  was  not 
recorded.  The  patient  has  been  well  without  recurrence 
for  a  year  and  over. 

Case  3  had  trouble  with  the  jaw  for  one  year.  A  fibro- 
sarcoma  was  removed.  There  has  been  no  recurrence  for 
eight  years. 

Case  4,  a  round-cell  sarcoma,  was  operated  upon  by  partial 
operation,  and  two  years  subsequently  there  is  no  recurrence. 

Of  this  group,  the  round-cell  sarcoma  alone  I  should 
exclude  from  the  routine  of  local  excision;  of  all  growths  of 
sarcoma  the  most  malignant,  it  should,  of  course,  be  most 
radically  dealt  with  in  the  light  of  our  present  knowledge. 

In  approaching  a  case  to  which  it  is  thought  likely 
that  a  partial  operation  may  pertain,  it  will  be  wise  to 
operate  tentatively,  to  'make  such  exposure  of  the  tumor 
by  an  incision  that  will  permit  subsequent  completion  of 
the  operation  as  a  most  radical  procedure,  if  necessary. 
The  microscopic  examination  should,  of  course,  go  hand 
in  hand  with  the  operation,  so  that  at  the  completion  of  the 
partial  steps  a  pathologic  report  may  be  forthcoming  from  the 
laboratory,  either  to  indicate  the  wisdom  of  the  partial  opera- 
tion or  to  suggest  a  more  radical  and  complete  operation. 


96 


TUMORS    OF    THE    JAWS 


Under  the  above  conditions  only  will  it  be  safe  for  any 
operating  surgeon  to  entertain  the  idea  of  a  partial  opera- 
tion for  malignant  disease. 

A  partial  operation  may  be  most  radical.  The  term 
should  not  be  allowed  to  mean  an  inefficient  operation. 

The  objects  of  a  partial  operation  are  the  complete 
removal  of  the  disease,  with  less  mutilation  and  better 
functional  results  than  by  any  other  method. 


A  Case  of  Round-cell  Sarcoma  of  the  Upper  Jaw.— 
A  woman,  thirty-six  years  old,  in  November,  1907,  no- 
ticed a  "gum-boil"  at  the 
inner  base  of  the  right  upper 
canine  tooth.  This  grew 
rapidly  to  the  size  of  a 
marble,  and  was  removed  by 
partial  excision  of  the  upper 
jaw  in  December,  1907.  It 
proved  to  be  a  small  round- 
cell  sarcoma.  Shortly  after 
she  noticed  an  enlargement 
of  the  glands  of  the  right 
side  of  the  neck,  which  were 
excised  in  February,  1908. 
Pathologic  report:  A  large 
round-cell  sarcoma.  Signed, 


Fig.  83. — Round-cell  sarcoma. 
Photograph  taken  just  after  dissection 
of  right  neck,  and  just  before  evidences 
of  recurrence  of  the  growth  appeared 
(Massachusetts  General  Hospital 
series) . 


W.  F.  Whitney. 

She  was  subsequently 
treated  by  Coley  toxins,  but 
in  April,  1908,  developed  a 
rapidly  growing  recurrence 

in  the  upper  lip  and  right  cheek.     She  was  readmitted,  but 
was    considered    inoperable,    and  died  June   14,  1908,  one 


SARCOMA   OF   THE   JAWS 


97 


year  and  five  months  following  the  discovery  of  the  sup- 
posed  gum-boil. 

This  case  illustrates  the  futility  of  partial  operation  in 


Fig.  84. — Round-cell  sarcoma. 
Same  as  Fig.  83  (Massachusetts 
General  Hospital  series). 


Fig.  85. — Round-cell  sarcoma  of 
the  right  upper  jaw.  Recurrent,  fol- 
lowing excision  of  the  upper  jaw  (com- 
pare with  Figs.  83  and  84)  (Massa- 
chusetts General  Hospital  series). 


cases  of  malignant  sarcoma,  the  uselessness  of  the  removal 
of  metastatic  glandular  enlargements  in  evidently  malig- 
nant sarcoma,  and  also  the  virulence  of  the  disease. 


Many  growths  starting  from  the  antrum  may  be  reached 
by  a  flap  of  the  cheek  turned  out  and  back,  the  anterior 
wall  of  the  antrum  being  removed;  the  growth  can  then 


98  TUMORS    OF   THE   JAWS 

be  scooped  out  thoroughly,  and  all  its  attached  portions 
excised.  The  cavity  of  the  antrum  may  be  packed  with 
gauze  tape  for  twenty-four  hours  or  more,  to  secure  hem- 
ostasis,  and  then  the  gauze  removed. 

If  the  alveolar  arch  is  involved,  a  portion  of  it  may  be 
excised,  as  is  done  in  the  case  of  epulis,  excepting  that  the 
excision  should  be  done  much  more  extensively. 

Significance  of  Early  vs.  Late  Operations. — The 
earlier  after  its  appearance  a  sarcoma  is  operated  upon, 
the  better.  Because  the  time  that  has  elapsed  since  the 
appearance  of  the  growth  is  short,  does  not  necessarily 
mean  that  the  operation  will  be  successful.  A  most  malig- 
nant type  of  the  disease  may  grow  rapidly  and  be  so  far 
advanced  that  even  though  it  is  a  relatively  and  apparently 
early  operation,  it  is  really  too  late.  It  is,  of  course,  true 
that  the  earlier  the  diagnosis  is  made,  and  the  earlier  the 
operation  is  done,  the  greater  is  the  likelihood  of  curing 
this  malignant  local  growth. 

Ultimate  Cures  Following  Operation  for  Sarcoma 
of  the  Upper  Jaw. — Recurrence  following  operation  for 
sarcoma  of  the  upper  jaws  certainly  is  the  rule.  Permanent 
cures  are  rare.  No  period  of  time  can  properly  and  safely 
be  set  as  that  within  which  a  case  may  be  called  cured. 

No  patient  should  be  considered  cured  if  he  has  ever  had 
a  sarcoma  of  the  jaw.  He  may  be,  with  propriety,  con- 
gratulated upon  being  and  continuing  to  remain  well,  but 
the  surgeon  must,  with  the  evidence  before  him  from  the 
best  European  and  many  American  clinics,  still  keep  in 
mind  the  possibility  of  an  appearance  of  the  disease- 
locally,  as  a  recurrence,  or  in  a  distant  part,  as  metastasis. 

Gussenbaum,  from  the  Vienna  clinic,  had  one  case  well 


SARCOMA    OF    THE    JAWS 


99 


for  four  years,  and  during  the  fourth  year  a  recurrence 
appeared. 

Kiister  records  a  case  who  had  a  recurrence  five  and  one- 
half  years  after  operation. 

Gussenbaum  had  7  apparent  cures.  He  was  able  to 
trace  all  but  1  of  the  7  cases  thought  to  be  cured.  He 


Fig.  86. — Sarcoma  of  the  upper  jaw.     Inoperable,  because  of  the  duration  of 
the  growth  and  its  extent  (Massachusetts  General  Hospital  series). 


found  that  6  were  dead — 5  surely  from  the  disease,  1  had 
had  two  operations  for  recurrence,  1  was  well  for  four 
years  and  then  had  a  recurrence. 

Martens  presents  an  interesting  series  of  cases  of  sarcoma 
of  the  upper  jaw  after  operation.  Total  resection  of  the  jaw 
for  sarcoma  was  performed  24  times.  There  were  4  deaths 
from  the  operation.  Of  the  20  cases  surviving  the  opera- 


100 


TUMORS    OF    THE    JAWS 


tion,  13  showed  recurrence  and  died.  Six  cases  were 
apparently  cured;  1  case  had  gone  less  than  three  years, 
so  Martens  did  not  consider  this  a  cure.  Of  these  7  possible 
cures,  2  were  round-cell  sarcoma,  1  was  a  round-  and  spindle- 
cell  sarcoma,  and  4  were  giant-cell  sarcoma. 

These  7  cases  have  lived  now  from   three  to  thirteen 
years  free  from  recurrence.     Four  of  them  have  lived  for 


Fig.  87. — Inoperable  sarcoma  of  the  upper  jaw.     Note  left  eye  displaced  up- 
ward and  inward  by  growing  tumor  (Massachusetts  General  Hospital  series). 

nine  years  free  from  recurrence.     No  glands  were  removed 
in  any  of  these  " cured"  cases. 

Martens  reports  3  partial  operations  for  sarcoma  of  the 
upper  jaw:  1  of  these  died  from  the  operation;  2  were 
cured,  "having  passed  the  three-year  limit";  1  case  was  an 
endothelioma  which  was  well  five  years  and  nine  months 
after  operation;  the  second  case  was  a  round-cell  sarcoma 


SARCOMA    OF    THE    JAWS 


101 


which  died  nine  years  after  operation,  free  from  recur- 
rence. 

Konig  thinks  that  the  five-year  period  is  the  fair  limit 
of  time  to  have  elapsed  for  a  case  to  be  considered  cured. 

Martens'  group  of  cases  is  most  instructive  and  should  be 
studied  with  eare.  There  were  74  operations  all  told  for 
carcinoma  and  sarcoma  upon  the  upper  jaw. 


Fig.  88. — Sarcoma  of  upper 
jaw  (Massachusetts  General  Hos- 
pital series). 


Fig.  89. — Sarcoma  of  upper  jaw 
(Massachusetts  General  Hospital 
series). 


P^orty-eight  cases  of  carcinoma — 19  deaths  from  opera- 
tion. 

Twenty-four  cases  of  sarcoma — 4  deaths  from  operation. 

Seventy-four  operations;  33  deaths  from  recurrence: 
20  of  these  were  carcinoma,  and  13  were  sarcoma. 


102  TUMORS    OF    THE    JAWS 

Of  the  total  resections,  there  were  16  permanent  cures— 
8  carcinoma,  6  sarcoma,  1  osteoma,  and  1  myxoma. 

Of   the    12  partial  resections,    9   were    carcinoma    and 
3  sarcoma.     One  of  the  sarcoma   cases  died  at  operation 
— 8.3  per  cent,  mortality.     Six  deaths  from  recurrence- 
all    carcinoma.     Two    permanent    sarcoma    cures.     Three 
cases  too  recent  to  consider. 


Fig.  90. — Sarcoma  of  the  upper  jaw.     Note  characteristic  fullness  in  temporal 

region. 

Kiister*  reports  14  sarcomata  of  the  upper  jaw — 9 
giant-cell  sarcoma;  all  were  permanently  cured.  Of  5 
malignant  sarcoma,  2  died  from  operation,  3  from  recurrence. 

The  fact  that  cures  are  recorded  following  operation 
for  sarcoma  in  which  the  lymphatics  were  not  removed 
and  were  not  thought  to  be  involved  means  that  the  glands 
are  involved  late  in  the  disease. 

In  Kronlein's  clinic,  according  to  BatzarofT,  in  33  cases 

*  Berlin,  klin.  Woch.,  1888,  Nos.  14,  15,  pp.  265,  296. 


SARCOMA   OF   THE   JAWS  103 

of  lower  jaw  periosteal  sarcoma  only  3  had  involvement  of 
the  lymph-glands. 

According  to  Martens,  in  27  cases  of  upper  jaw  sarcoma 
in  Konig's  clinic,  in  only  2  cases  were  there  metastases, 
and  these  were  cases  of  melanotic  sarcoma. 

Cases  of  Sarcoma  from  the  Massachusetts  Gen- 
eral Hospital  Clinic. — I  have  studied  with  great  care  the 


Fig.  91. — Sarcoma  of  the  upper  jaw.  Appearances  of  a  secondary  recur- 
rence following  two  operations.  This  illustrates  the  very  great  local  malig- 
nancy of  the  growth  (Kaposi). 


cases  of  sarcoma  of  the  jaws  in  the  Massachusetts  General 
Hospital  clinic. 

From  1898  to  1906,  26  cases  upon  which  operations  have 
been  done  are  recorded. 

There  were  11  sarcomata  of  the  upper  jaw  and  15 
sarcomata  of  the  lower  jaw. 


104  TUMORS    OF    THE    JAWS 

Of  the  11  upper  jaw  cases  (11  patients),  8  cases  have 
been  followed  subsequently  to  the  operation  sufficiently 
long  to  make  the  records  of  value. 

RESULTS  IN   EIGHT   UPPER   JAW   SARCOMA  CASES  AFTER 

OPERATION 

1  alive  and  well  eight  years  after  operation — fibrosarcoma. 

1  alive  and  well  nine  years  after  operation — spindle-cell 
sarcoma. 

1  alive  and  well  five  years  after  operation — osteosarcoma. 

1  alive  and  well  eight  years  after  operation — fibrosarcoma. 

1  lived  two  years  and  died  of  recurrence  two  years  after 
operation — round-cell  sarcoma. 

1  alive  and  well  ten  years  after  operation;  cell  not  speci- 
fied— sarcoma. 

1  alive  two  years  after  first  operation  and  one  year  after 
second  operation — giant-cell  sarcoma.  Resection 
both  upper  jaws.  Had  carcinoma  uteri.  Died  of 
carcinoma  of  uterus.  No  recurrence  at  seat  of  jaw 
operation. 

1  died  after  complete  excision;  round-cell  sarcoma — ligation 
of  external  carotid — cerebral  embolism. 

Of  the  12  cases  of  removal  of  the  upper  jaw  in  whole  or 
in  part  only  1  died,  and  this  one  from  embolism  following 
ligation  of  the  external  carotid.  The  embolus  was  detached 
and  followed  the  internal  carotid,  as  was  demonstrated  by 
autopsy. 

There  were  6  complete  excisions  of  the  upper  jaw  in  5 
patients,  1  patient  having  had  each  upper  jaw  removed  at 
different  operations  one  year  apart. 


SARCOMA   OF   THE    JAWS  105 

Six  COMPLETE  UPPER  JAW  EXCISIONS 

1  is  alive  and  well  eight  years  after  the  first  operation,  having 

had  several  small  recurrences. 
1  died  nine  years  after  operation.     Exact  cause  of  death 

not  known. 
1  lost  sight  of. 
1  died  of  embolism  after  operation. 


Fig.  92. — Sarcoma  of  the  upper  jaw.  Note  the  great  pressure  upon  the 
eyeball,  the  distortion  of  the  nose  and  mouth,  and  the  very  great  evident  dis- 
comfort to  the  individual  by  the  tremendous  pressure  (Leipsic  clinic). 

1  had  one  jaw  removed  and  then  the  other  jaw  one  year 
later — one  individual,  2  operations.  No  local  re- 
currence, but  patient  had  carcinoma  uteri  and  died 
of  cancer. 

There  were  6  partial  operations  upon  the  upper  jaw. 
Among  the  partial  operations  there  were  no  deaths. 


106  TUMORS    OF   THE   JAWS 

Six  PARTIAL  OPERATIONS 

1  was  alive  eight  years  after  operation — a  fibrosarcoma. 
1  was  alive  five  years  after  operation — an  osteosarcoma. 
1  lived  two  years  after  operation  and  died — a  round-cell 

sarcoma. 
1  was  alive  ten  years  after  operation — sarcoma. 


Fig.  93. — Sarcoma  of  the  upper  jaw.     Note  the  very  great  edema  of  the  eye- 
lids, the  tumor  of  the  left  upper  jaw  (Leipsic  clinic). 

1  was  known  to  have  a  recurrence  five  months  after  oper- 
ation which  was  inoperable — round-cell  sarcoma. 

1  nothing  has  been  heard  of  since  operation — perithelioma, 
spindle-cell  sarcoma. 

Martens  thinks  that  life  is  prolonged  after  operations 
for  sarcoma  of  the  upper  jaw.  At  the  Massachusetts 
General  Hospital  clinic,  in  cases  of  upper  jaw  sarcoma 
traced  and  not  living  or  not  known  to  be  living  at  present — 


SARCOMA    OF   THE   JAWS  107 

1  case  of  spindle-cell  sarcoma  lived  three  years  following 
operation,  and  for  two  years  without  any  local  recur- 
rence. 

1  case  had  a  recurrence  (round-cell  sarcoma)  three  months 
following  operation. 

1  case  of  round-cell  sarcoma  lived  two  years  after  operation. 

1  case  of  round-cell  sarcoma  died  from  embolism,  cerebral, 
post-operative. 

1  case  of  giant-cell  is  dead,  without  recurrence,  with  car- 
cinoma of  the  uterus. 


Fig  94. — Sarcoma  of  the  upper  jaw  extending  to  nose,  orbit,  cheek,  and  tem- 
poral region.     Inoperable  (Heidelberg  clinic). 

Should  Operation  be  Done  in  Every  Case? — Al- 
though the  ultimate  cures  are  few,  yet  it  is  seen  that  just 
in  proportion  as  the  work  is  done  thoroughly,  the  results 
are  best.  There  is  great  room  for  encouragement  to  the 
surgeon.  Sarcoma  behaves  as  a  local  disease  with  few 


108  TUMORS    OF   THE   JAWS 

early  metastases  and  with  little  early  glandular  involve- 
ment. Metastases  from  upper  jaw  tumors  are  rarer  than 
from  new-growths  elsewhere.  The  tendency  at  the  Massa- 
chusetts General  Hospital  clinic,  where  the  teaching  of 
Warren  has  been  personally  felt,  is  to  regard  sarcoma  of 
the  upper  jaw  as  most  malignant  in  its  tendency  to  recur 
locally  at  the  site  of  the  operation.  Konig,  of  Gottingen, 


Fig.  95. — Sarcoma  of  the  upper  jaw.     Total  resection  wa«  done,  but  recurrence 
caused  death.     A  malignant  type  of  growth  (Trendelenburg) . 

evidently  feels  the  same  way  about  this  matter.  Note  the 
case  of  Steele  at  the  Massachusetts  General  Hospital  clinic, 
in  which  some  12  or  more  operations  have  been  done  for 
local  recurrence.  Note  the  case  of  Winch  from  the  same 
clinic,  the  very  rapid  recurrence  of  whose  growth  is  illus- 
trated in  Figs.  84  and  85. 

Is  the  Growth  One  Which  it  is  Wise  to  Attempt 
to  Remove? — It  may  sometimes  be  impossible  to  decide, 


SARCOMA    OF    THE    JAWS 


109 


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110  TUMORS    OF   THE   JAWS 

previous  to  an  exploratory  incision,  whether  or  not  it  is 
worth  while  attempting  the  removal  of  a  tumor  of  the 
upper  jaw.  Each  case  must  be  decided  separately,  and  the 
decision,  to  be  a  just  and  safe  one,  must  be  based  upon  a 
knowledge  of  all  the  facts  available. 

The  slowly  growing  growths  which  have  been  present 
some  time  are  hard  and  pretty  well  defined  and  well  local- 
ized so  far  as  the  jaw  is  concerned.  When  the  skin  and 
mucous  membrane  are  uninvolved,  these  growths  are  very 
likely  to  be  amenable  to  surgical  treatment.  Among  these 
will  be  found  the  fibrosarcomata  and  osteosarcomata. 

On  the  other  hand,  growths  of  a  few  months'  duration, 
which  are  soft  and  vascular,  rather  ill  defined,  in  which  the 
skin  is  involved,  the  orbit  or  temple  invaded,  with  an  enlarge- 
ment of  the  submaxillary  and  submental  glands,  as  pointed 
out  by  Jackson — such  growths  are  likely  to  be  difficult  of 
removal. 

If  it  is  likely  that  the  sarcoma  cannot  be  completely 
removed,  I  believe  the  situation  should  be  stated  to  the 
individual  and  his  friends,  and  operation  should  be  refused. 
Operation  under  such  circumstances  will  be  of  little  or  no 
comfort,  and  is  at  best  distasteful  to  the  individual.  Many 
cases  which  have  been  unsuccessfully  operated  upon  are 
seen  by  surgeons  and  internists,  and  I  believe  the  consensus 
of  opinion  is  that  such  patients,  taking  everything  into 
consideration,  would  have  been  fully  as  comfortable  if  they 
had  been  unoperated  upon. 

The  disease  almost  always  recurs  in  situ,  and  rather 
early  after  operation. 

There  are  a  few  cases,  as  pointed  out  by  Butlin,  which 
are  benefited  by  the  comparatively  long  interval  between 


SARCOMA   OF   THE   JAWS  111 

the  removal  of  the  disease  and  its  reappearance.  Many 
operations  are  doubtless  begun  and  abandoned  as  hopeless 
which  had  much  better  not  have  been  attempted  at  all. 

Necessity  for  Dissection  of  the  Neck  in  Sarcoma.— 
If  the  glands  in  the  neck  are  palpable,  I  believe  that  they 
should  be  removed  by  dissection  of  the  whole  side  of  the 
neck.  In  the  very  malignant  operable  sarcomata  it  would 


Fig.  96. — Sarcoma  of  the  upper  jaw.     Note  the  displacement  of  the  nose, 
the  swelling  in  front  of  the  ear,  the  deformity  of  the  mouth  (Leipsic  clinic) . 

seem  wise  to  dissect  the  neck  in  each  case  with  great  care. 
In  none  of  the  sarcoma  cases  at  the  Massachusetts  General 
Hospital  clinic  were  the  lymphatics  of  the  neck  primarily 
removed.  In  very  few  of  the  sarcomata  of  the  upper 
maxilla  reported  from  foreign  clinics  were  the  neck  lym- 
phatics removed.  Recurrence  takes  place  locally,  and  rarely 
are  the  glands  involved. 


112 


TUMORS    OF    THE    JAWS 


A  Case  of  Inoperable  Sarcoma  of  the  Upper  Jaw.— 
T.  G.,  thirty-eight  years  old.  Massachusetts  General  Hos- 
pital record  No.  159611.  August  5,  1908. 

Three  years  ago  the  tumor  appeared  on  the  right  side 
of  the  nose.  It  was  removed  two  years  ago.  One  year  ago 
it  had  recurred,  and  has  been  growing  rapidly  for  the  past 


Fig  97. — Round-cell  sarcoma  of 
the  upper  jaw.  Note  bulging  of  cheek 
and  displacement  of  eyeball.  A  very 
vascular  and  consequently  rapidly 
growing  tumor.  At  this  stage  of  its 
extension  it  is  inoperable. 


Fig.  98.  —  Round-cell  sar- 
coma of  the  upper  jaw,  starting 
from  the  antrum  and  gradually 
but  rapidly  invading  the  nasal 
cavity,  orbit,  and  cheek.  Note 
growth  protruding  from  right 
nostril,  bulging  of  cheek,  dis- 
placement of  eyeball,  displace- 
ment of  nose,  fullness  in  inner 
canthus. 


six   months.     It   was   treated   with   Coley   toxins   without 
benefit. 

Pathologic  report:  Myxomatous  stroma  with  con- 
siderable necrosis  and  marked  overgrowth  of  blood-  and 
lymph-vessels.  Diagnosis:  Myxosarcoma. 


SARCOMA   OF   THE   JAWS  113 

When  do  Recurrences  Appear  and  Where? — Recur- 
rence appears  locally  after  removal  of  the  sarcoma.  There- 
fore a  very  radical  primary  local  operation  should  be  done. 
The  recurrence  shows  itself  rather  early  after  operation— 
that  is,  within  a  few  weeks,  or  at  most  a  very  few  months. 
This  suggests  that  possibly  the  trauma  of  incision  is  a 
contributing  factor  to  recurrence. 

The  lymph-glands  were  involved  three  times  in  Martens' 
series — once  in  an  alveolar  melanotic  sarcoma;  once  in  a 
spindle-cell  sarcoma  arising  in  the  palate,  and  once  in  a 
round-cell  sarcoma. 

It  may  be  put  down  that,  as  a  rule,  the  lymph-glands 
are  rarely  involved  in  upper  jaw  sarcomata,  whereas  in 
lower  jaw  sarcomata  an  enlargement  is  more  common. 

The  time  of  the  appearance  of  the  recurrence  after  oper- 
ation is  of  interest.  Stein  records  four  cases  of  upper  jaw 
sarcoma  in  which  recurrence  appeared  in  two  cases  one 
month,  in  one  case  one  and  one-half  months,  and  in  one  case 
twelve  months,  after  operation.  In  two  of  these  four  cases 
death  followed  six  months  after  operation. 

Martens,  in  his  record  of  Konig's  clinic,  finds  that  5 
patients  died  one  to  five  months,  and  three  patients  six  to 
ten  months,  after  operation  on  the  upper  jaw. 

Six  of  the  lower  jaw  cases  operated  upon  died  at  these 
different  periods  after  operation — three  months,  six  months, 
seven  months,  one  year,  three  and  one-quarter  years,  six 
years. 

In  general,  it  may  be  said  that  if  recurrence  is  to  take 
place  after  an  operation  for  sarcoma  of  the  upper  or  lower 
jaws,  it  will  appear  within  six  to  twelve  months  following 
operation. 

8 


114 


TUMORS    OF    THE    JAWS 


Necessity  for  Removal  of  the  Eye.  Necessity  for 
Removal  of  the  Orbital  Plate. — Butlin  thinks  that  the 
necessity  for  the  removal  of  the  orbital  plate  has  not  yet 
been  fully  established.  The  deformity  occasioned  by  the 
removal  of  the  orbital  plate,  together  with  the  more  im- 
portant fact  that  the  eye  so  deprived  of  its  inferior  support 
is  practically  thrown  out  of  commission,  should  lead  one 

to  hesitate  to  remove  the 
orbital  plate  unless  it  is  abso- 
lutely necessary.  Of  course, 
if  the  eye  is  to  be  enucleated 
at  the  same  time  in  order 
to  get  at  the  disease  more 
readily,  then  the  orbital  plate 
must  be  removed. 

The  tendency  of  the  dis- 
ease in  the  antrum,  and  when 
extending  on  to  the  cheek,  is 
to  invade  the  orbit.  When 
the  corner  of  the  orbit  next 
the  lacrimal  duct  is  involved, 
then  I  believe  the  eye  should 
be  enucleated.  I  think  that 
it  is  absolutely  impossible  to 
get  at  the  disease  and  preserve  the  eye  under  these  condi- 
tions. 

In  Martens'  74  upper  jaw  operations,  10  times  at  the 
primary  operation  the  eye  was  removed  with  the  growth. 
Once  the  eye  was  removed  secondarily  for  panophthalmitis. 
Martens  thinks  the  eye  is  of  less  importance  than  the 
life  of  the  individual.  He  believes  that  the  orbital  plate 
is  to  be  removed  always  with  the  upper  jaw. 


Fig.  99. — Sarcoma  of  the  lower 
jaw  in  an  elderly  person  (Massa- 
chusetts General  Hospital,  collection 
of  C.  B.  Porter). 


SARCOMA    OF   THE    JAWS 


115 


OPERATIVE   TREATMENT   OF   UPPER   AND    LOWER   JAW   SAR- 
COMATA.    RESULTS  FROM  EUROPEAN  CLINICS 


RE- 

DEAD FROM 

OPERATOR. 

COVERED 

FROM 

RECURRENCE 
OR  LIVING 

OPERA- 

WITH RECUR- 

TION. 

RENCE. 

AFTER  THREE 
NOT      :    YEARS  FREE 
FOUND.       FROM  RECUR- 
HENCE. 


(a)  TOTAL  RESECTIONS 


Upper  jaw: 

Billrpth,  1871-76 

Konig,  1875-99  (Martens) 

Von  Bergmann,  1890-1900 

(Stein) ;  ..  .  . 

Lower  jaw: 

Konig.  1875-1902  (Behm) 


Total . 


9 
20 

11 


13 


48 


24 


ib)  PARTIAL  OPERATIONS 


Upper  jaw: 

Konig,  1875-99  (Martens) 

Von  Bergmann.  1890-1900 

(Stein) 

Lower  jaw: 

Konig,  1875-1902  (Behm) 


Total. 


10 


17 


4 
6 

4 
2 

16 


(C)    SARCOMA   OF  THE   LOWER  JAW 

The  clinical  characteristics  hitherto  mentioned  likewise 
pertain  to  sarcoma  of  the  lower  jaw,  excepting  for  the 
necessary  change  in  the  anatomic  relations. 

Kinds  of  Sarcoma. — The  sarcomata  of  the  lower  jaw 
are  usually  either  subperiosteal  or  central  in  origin.  The 
periosteal  growths  may  be  of  three  types  of  cells — round, 
spindle,  or  mixed.  The  central  growths  may  be  of  these 
three  types  of  cells  or  giant-cells.  The  giant-cell  growths 
are  the  most  frequent  of  the  sarcomata  in  the  lower  jaw. 


116 


TUMORS    OF   THE    JAWS 


The  progress  of  the  tumors  of  periosteal  origin  is  usually 
not  by  invasion  of  the  bone  from  without.  The  bone  may 
be  surrounded,  but  rarely  invaded. 

Rate  of  Growth. — The  sarcoma  of  the  lower  jaw  is 
often  of  very  slow  growth.  The  tumor,  at  first,  as  in  the 
upper  jaw,  if  palpable  there,  is  smooth  on  the  exposed 

surface,  firm,  elastic,  and  in- 
timately connected  with  the 
jaw.  Only  occasionally  is  it 
painful,  often  painless.  It  is 
situated  in  the  body  of  the 
jaw,  near  and  in  front  of  the 
angle.  It  is  of  slow  growth. 
The  story  is  one  of  ulcerated 
teeth,  extraction  of  certain 
teeth,  a  thickening  at  the 
place  of  the  extracted  teeth, 
which  later  becomes  the 
tumor. 

The  mucous  membrane, 
and  occasionally  the  skin 
over  the  tumor,  will  be  ulcer- 
ated. If  the  mass  becomes 
very  large,  it  may  obstruct  swallowing  and  render  breath- 
ing difficult  by  dislocating  the  tongue. 

If  the  growth  be  melanotic,  and  hence  very  soft  and 
highly  vascular,  and  consequently  very  malignant,  palpation 
will  find  a  soft,  elastic  mass,  near  perhaps  to  the  wisdom- 
teeth,  attached  to  the  jaw,  of  rapid  development.  The 
mass  bleeds  easily  when  injured. 

So  malignant   is   the   malignant   sarcoma   that   a   very 


Fig.  100. — Sarcoma  of  upper  jaw. 
Illustrating  the  very  extensive  spread 
of  the  disease  (Massachusetts  General 
Hospital,  collection  of  C.  B.  Porter). 


SARCOMA    OF    THE    JAWS 


117 


early  recognition  of  it  is  essential  to  any  diminution  of  the 
present  high  percentage  of  recurrence  with  death  following 
operation. 

Operative  Mortality  of  Lower  Jaw  Sarcoma.— 
Butlin  finds  that  of  60  cases  of  lower  jaw  operations  8  died; 
Lticke  finds  that  following  removal  of  one-half  the  lower 
jaw  in  17  cases  there  were  4  deaths;  Heath  records  7 
cases  of  Cusack  with  1  death;  Dupuytren  records  20 


Fig.  101. — Recurrent  sarcoma  of  the  right  upper  jaw.     Note  that  the  recur- 
rence is  seen  to  be  local  and  very  extensive  (Kaposi,  Heidelberg  clinic). 

cases  with  1  death — making  a  total  of  104  cases  with  14 
deaths,  or  less  than  14  per  cent. 

St.  Bartholomew's  Hospital  cases  from  1887  to  1897 
amounted  to  10  with  1  death. 

In  the  Massachusetts  General  Hospital  list  there  have 
been  no  deaths  due  to  the  operation. 


118 


TUMORS    OF   THE    JAWS 


The  common  causes  of  death  in  these  reported  cases  were 
sepsis,  hemorrhage,  and  shock. 

Statistics — those  of  Webber,  etc. — derived  from  the 
older  groups  of  cases  are  of  value  only  in  a  most  general 
way. 

The  Ultimate  Results  of  Operation  for  Sarcoma 
of  the  Lower  Jaw. — Butlin  has  collected  19  cases  of  sub- 
periosteal  sarcoma  and  43  cases  of  central  sarcoma.  Of  the 


Fig.  102.—  Osteosarcoma  of  the 
right  half  of  the  lower  jaw.  Note 
large  size,  uniform  surface  (Duncan 

Eve). 


Fig.  103. — Osteosarcoma  of  the 
right  half  of  the  lower  jaw.  After 
operation  by  resection  (Duncan 
Eve). 


19  cases  of  subperiosteal  sarcoma,  there  was  no  death  from 
the  operation.  Eight  were  dead  or  dying  of  recurrence, 
and  not  one  was  alive  twelve  months  after  operation.  One 
died  of  secondary  mediastinal  disease  four  and  a  half  months 
later.  One  died  of  pneumonia  after  two  months.  Eight 
were  lost  sight  of.  One  was  alive  and  well  two  and  one- 
half  years  after  operation. 

The  tumors  were  nearly  all  either  round-  or  spindle-cell. 


SARCOMA   OF   THE   JAWS 


119 


The  successful  case  was  that  of  Mears,  of  Philadelphia, 
and  was  a  round-cell  sarcoma. 


A  Case  of  Sarcoma  of  the  Lower  Jaw,  Followed 
by  Carcinoma  and  Carcinomatous  Invasion  of  the 
Lymphatic  Glands,  Occurring  in  the  Massachusetts 
General  Hospital  Clinic. — An  unusual  and  extremely 
important  and  instructive  case,  occurring  in  the  Mass- 
achusetts General  Hospital  clinic,  was  that  of  an  adult  man, 


Fig.  104. — Sarcoma  of  the  lower  jaw  on  right  side.     (See  Fig.  105.) 

fifty  years  old.  Six  years  previous  to  the  present 
observation  he  had  had  several  lower  teeth  extracted. 
Since  that  time  he  had  a  series  of  gum-boils.  Six  weeks 
previous  to  October,  1905,  he  first  noticed  a  rapidly 
growing  tumor  at  the  base  of  the  second  left  lower 
molar  tooth. 

Examination  of  this  tumor  discovered  a  mass  the  size 


120 


TUMORS    OF   THE    JAWS 


of  a  chestnut.  There  was  no  glandular  enlargement  palp- 
able. Microscopic  examination  of  a  specimen  from  this  mass 
proved  it  to  be  a  spindle-cell  sarcoma. 

In  October,  1905,  the  jaw  was  operated  upon.  (See  Fig. 
104.)  A  partial  excision  and  curetage  was  done,  together 
with  the  removal  of  the  non-palpable  submental  glands. 

In  August,  1907,  a  second  operation  was  done,  removing 


Fig.  105. — Glands  of  the  neck  dissected  out  in  case  of  sarcoma  of  the  jaw 
shown  in  previous  figure,  nearly  two  years  after  the  jaw  operation  (Fig.  104). 
Carcinoma  of  the  glands.  These  glands  naturally  were  thought  clinically 
to  be  sarcomatous.  They  proved  to  be  carcinomatous. 

a  few  enlarged  lymphatic  glands  beneath  the  jaw.     These 
glands  proved  to  be  invaded  by  carcinoma. 

In  November,  1907,  because  of  an  evident  recurrence 
at  the  site  of  the  October,  1905,  operation,  a  resection  of 
one-half  of  the  lower  jaw  was  done.  The  neck  upon  the 
diseased  side  was  thoroughly  dissected,  the  external  carotid 
being  ligated.  Seven  days  later  the  autopsy  disclosed  a 


SARCOMA    OF    THE    JAWS 


121 


septic  thrombus  of  the  carotid.     The  growth  from  the  lower 
jaw  proved  to  be  carcinoma. 

Summary:  An  adult  with  sarcoma  of  the  lower  jaw; 
local  excision  done.  Two  years  later  enlarged  glands  in 
the  neck  and  apparently  a  recurrence  at  the  seat  of  the 
original  operation.  Three  months  later  an  excision  of 
one-half  of  the  jaw  was  done,  and  the  disease  found  to  be 


Fig.  106. — Three  months  after  removal  of  the  carcinomatous  glands. 
Reappearance  of  tumor  at  site  of  jaw  operation.  Proved  to  be  carcinoma. 
(See  Fig.  105.)  Patient  died  of  sepsis  following  jaw  operation. 


carcinoma.     In  this  case  we  find  illustrated  the  appearance 
of  two  different  tumors  at  the  same  spot. 

A  glance  at  the  three  micropho,togra~phlf  (Figs.  104, 
105,  106)  shows  the  appearance  of  both  the  jaw  tumor,  the 
glandular  recurrence,  and  the  carcinoma  ingrafted  upon 
the  base  of  the  original  sarcoma.  These  microphoto- 
graphs  were  made  by  Mr.  Brown,  of  the  Pathologic  Labor- 
atory of  the  Massachusetts  General  Hospital,  from  sec- 


122  TUMORS   OF   THE   JAWS 

tions   prepared   and    reported    upon   by   W.   F.    Whitney, 
pathologist  to  the  Massachusetts  General  Hospital. 


Of  the  15  lower  jaw  sarcomata  from  the  Massachusetts 
General  Hospital  clinic,  the  following  are  the  end-results: 
1  lived  three  years;  recurrence  after  two  years — spindle-cell. 
1  lived  six  years,  then  lost  sight  of — lymphangiosarcoma. 
1  lived  seven  years — osteofibrosarcoma. 
1  lived  one  and  one-half  years;   recurrence  in  seven  months 

—spindle-cell. 

1    living    seven    years — adamantine  epithelioma   with  sar- 
coma. 

1  living  seven  years — giant-cell  sarcoma. 
1  lived  two  years,  recurrence  in  one  year — round-cell. 
1  untraced — sarcoma. 
1  •  untraced — perithelioma. 

1  recurrence  in  four  months — melanotic  sarcoma. 
1  living  four  years— osteosarcoma. 
1  untraced — round-cell  sarcoma. 
1  lived  one  year,  unheard  from — round-cell  sarcoma. 
1  untraced — fibrosarcoma. 
1  lived  two  years,  recurrence  in  one  year — died. 

None  of  the  15  died  because  of  operation. 

Of  these  15  cases  of  sarcoma  of  the  lower  jaw,  it  has 
been  impossible  to  find  4  cases.  One  diagnosis  of  simply 
" sarcoma"  was  made.  The  predominant  variety  of  cell 
is  not  always  stated.  One  was  a  perithelioma,  one  was  a 
round-cell  sarcoma,  and  one  was  a  fibrosarcoma. 

There  have  been  recurrences  in  5  cases: 


SARCOMA    OF   THE    JAWS  123 

In  1  case  after  two  years'  freedom  from  disease — a  spindle- 
cell. 

In  1  case  after  seven  months — a  spindle-cell. 
In  1  case  after* one  year — a  round-cell. 
In  1  case  after  some  months — a  spindle-cell. 
In  1  case  after  four  months — a  melanotic  sarcoma. 


Fig.  107. — Periosteal  osteosarcoma  of  the  lower  jaw.  Note  the  uniformly 
smooth-appearing  swelling  of  the  lower  left  jaw;  the  swelling  extends  high, 
near  to  the  ear,  even  though  the  tumor  is  confined  to  the  body  of  the  left  half 
of  the  jaw  (Bloodgood). 

The  following  six  cases  have  lived  and  are  living  after 
operation,  with  no  known  recurrence: 
1  case  six  years  after  operation  for  lymphangiosarcoma. 
1  case  seven  years  after  operation  for  osteofibrosarcoma. 
1  case  seven  years  after  operation  for  adamantine  epithe- 
lioma  with  sarcoma. 


124  TUMORS   OF   THE   JAWS 

1  case  seven  years  after  operation  for  giant-cell  sarcoma. 

1  case  four  years  after  operation  for  sarcoma. 

1  case  one  year  after  operation  for  round-cell  sarcoma. 

Duration  of  the  Disease  Previous  to  Operation.— 
The  disease  had  existed,  so  far  as  could  be  determined 
previous  to  operation  in  the  cases  of  lower  jaw  sarcomata 
from  the  Massachusetts  General  Hospital  series,  one  year, 
some  time,  six  months,  three  months,  four  months,  one  and 
one-half  years,  eight  months,  two  years,  one  and  one-half 


Fig.  108. — Periosteal  osteosarcoma.    (See  Fig.  107.)    Inner  view  of  tumor.    A, 
Bony  section  of  jaw   (Bloodgood). 

years,  three  months,  three  months,  three  months,  respec- 
tively. 

A  spindle-cell  sarcoma  noticed  the  growth  for  one  year 
and  lived  three  years  after  operation,  having  a  recurrence 
after  two  years.  A  giant-cell  noticed  the  growth  one  and 
one-half  years  previous  to  operation,  and  is  alive  and  with- 
out recurrence  seven  years  following  operation. 

Other  things  being  equal,  the  earlier  operation  can  be 
done  after  the  growth  is  discovered,  the  better  is  the  chance 


SARCOMA    OF    THE    JAWS  125 

of  cure.  But  it  must  be  considered  that  some  of  the  slow 
growths  are  most  malignant,  so  that  even  though  a  growth 
be  operated  upon  within  a  few  weeks  of  its  discovery,  the 
result  may  not  be  good  despite  the  early  operative  attack, 
for  it  may  be  a  most  malignant  type.  The  character  of 
the  cell  is  of  more  importance  than  the  time  of  the  operation 
after  discovery  in  suggesting  the  resulting  prognosis. 

In  the  most  successful  cases  the  disease  had  been  known 
to  have  existed  six  months,  four  months,  one  and  one-half 
years,  three  months,  and  three  months  respectively.  The 
one  and  one-half  year  period  was  in  the  case  of  a  giant-cell 
sarcoma. 


Cases  of  Sarcoma  of  the  Lower  Jaw 

A  detailed  account  is  here  presented  of  certain  of  the 
cases  studied.  Such  a  narrative  makes  clearer  the  clinical 
picture  of  the  group.  Each  case  described  is  designated  by 
the  name  used  in  the  tabulated  list. 

Case:  Simpson.  A  woman,  thirty-five  years  old,  had 
a  hard  smooth  lump  of  slow  growth  for  over  a  year  upon 
the  right  lower  jaw.  This  lump  was  the  size  of  an  English 
walnut.  The  gum  over  the  tumor  was  ulcerated.  The 
tumor  was  intimately  connected  with  the  jaw.  Sometimes 
there  was  pain  in  the  tumor.  A  few  weeks  previous  to 
examination  there  had  been  an  ulcerated  tooth  upon  the 
same  side  of  the  jaw  as  the  new-growth. 

One-half  the  lower  jaw  was  removed.  The  growth  was 
a  spindle-cell  sarcoma  surrounding  the  greater  part  of  the 
jaw,  which  was  extensively  destroyed  by  it.  Two  years 
later  a  large  infiltrating,  solid,  and  painful  mass  was  found 
at  the  angle  of  the  jaw,  which  was  thought  inoperable.  The 


126  TUMORS    OF   THE   JAWS 

patient  lived  one  year  after  this,  or  three  years  from  the 
time  of  the  operation. 

Case:  Green.  A  man,  fifty-five  years  old,  had  a  tooth 
extracted  from  the  left  lower  jaw  (bicuspid  tooth)  nine 
years  previously.  He  thinks  that  the  jaw  was  fractured 
at  that  time.  At  any  rate,  a  hard  lump  appeared  in  the 
gum  where  the  tooth  had  been  and  grew  slowly  and  pain- 


Fig.  109. — Tumor  cut  open,  showing  shaft  of  lower  jaw,  surrounded  by  peri- 
osteal  osteosarcoma  (Bloodgood). 

lessly.  In  the  mouth  and  neck  (see  Figs.  61  and  62)  appeared 
a  large  mass,  ulcerated  within  the  mouth,  giving  trouble  from 
its  weight.  Chewing  was  difficult.  The  skin  over  the  mass 
finally  ulcerated,  allowing  blood  and  serum  to  discharge. 

The  tumor  was  shelled  out  and  half  the  jaw  removed. 
It  proved  to  a  cystic  lymphangiosarcoma.  It  had  a  soft 
medullary  consistence,  with  many  cysts  scattered  through 
it.  The  man  was  alive  and  well  six  vears  later. 


SARCOMA    OF    THE    JAWS 


127 


Case:  Bowles.  A  boy,  ten  years  old.  Six  months  ago 
he  was  hit  with  a  baseball  bat  a  severe  blow  upon  the  lower 
jaw,  knocking  him  over  so  that  he  fell  to  the  ground.  Three 
weeks  after  the  fall  there  appeared  to  be  a  hard,  painless 
swelling  upon  the  lower  right  jaw,  near  the  angle  where  the 
blow  had  been  received.  The  tumor  was  2  inches  by  Yi 
inch  in  size  as  roughly  measured.  For  three  months  it 
grew  slowly.  The  first  operation  was  partial  only,  as  it 


Fig.  110. — Sarcoma  of  the  upper 
jaw  in  a  boy  of  ten  years  (foreign 
clinic). 


Fig.  111. — Sarcoma  of  the 
upper  jaw  in  a  boy  of  ten  years,  after 
operation.  Resection  of  each  upper 
jaw.  Note  the  symmetric  cicatrices 
across  both  cheeks  and  slight  de- 
formity. 


was  thought  that  the  swelling  was  associated  with  caries; 
three  months  afterward  one-half  the  jaw  was  removed  for 
examination,  and  the  growth  found  to  be  an  osteosarcoma. 
This  boy  was  well  seven  years  after  the  latter  operation. 

Case:  Turner.  A  man  forty-five  years  old  had  ulcerated 
teeth  for  at  least  three  months.  The  gum  of  the  left 
lower  jaw  was  greatly  swollen.  Three  weeks  ago  a  tooth 


128  TUMORS    OF    THE    JAWS 

situated  within  the  swollen  area  was  pulled.  A  hard  red 
ulcerated  mass,  size  of  an  English  walnut,  appeared  at  the 
socket  of  the  extracted  tooth.  He  had  considerable  pain 
in  the  swelling  on  the  jaw.  The  pain  was  severe  enough  to 
keep  him  from  his  work.  The  tumor  had  grown  slowly. 
The  glands  in  the  submaxillary  region  were  enlarged. 

One  half  the  lower  jaw  was  removed.  The  growth 
proved  to  be  a  spindle-cell  sarcoma.  The  man  lived  a  year 
and  a  half,  but  recurrence  at  the  seat  of  the  operation 
appeared  seven  months  thereafter. 

Case:  Coit.  A  boy,  thirteen  years  old,  was  kicked  hard 
in  the  chin  while  playing  football  one  and  one-half  years 
previously.  Three  weeks  after  the  kick  a  swelling  of  the 
jaw  existed,  which  remained  in  size  pretty  constant  (a  hen's 
egg).  When  the  boy's  chin  was  examined,  there  was  found 
(see  Figs.  51-56)  a  mass  the  size  of  a  hen's  egg,  extending  from 
the  first  right  molar  to  the  first  left  bicuspid.  A  shell  of 
bone  covered  the  growth,  which  was  so  soft  as  almost  to  give 
the  sense  of  fluctuation.  The  mass  was  purplish  in  color. 
Several  enlarged  superficial  veins  covered  it.  The  swelling 
was  the  same  size  inside  and  outside  the  lower  lip. 

The  lower  jaw  was  cut  away,  and  excised  well  outside 
the  limits  of  the  growth.  The  tumor  was  a  giant-cell 
sarcoma  starting  from  the  center  of  the  bone.  Seven  years 
after  operation  the  boy  is  well,  with  no  signs  of  recurrence. 

Case:  Brown.  A  man,  sixty-two  years  old,  had  noticed 
a  swelling  of  the  right  lower  jaw  for  about  twelve  weeks. 
This  swelling  had  increased  rapidly  under  the  use,  as  then 
applied,  of  the  Roentgen  ray.  There  appeared  about  the 
wisdom  tooth  a  mass  which  was  ulcerated  and  bled  easily. 
The  mass  first  noted  was  visible  externally  at  the  angle  of 
the  jaw,  and  was  intimately  attached  to  the  jaw. 

The  tumor  was  removed  from  the  lower  jaw  by  a  chisel. 
A  few  months  later  a  piece  of  the  jaw  was  removed  cor- 


SARCOMA   OF   THE   JAWS  129 

responding  to  the  oval  mass.     This  new-growth  proved  to 
be  a  melanotic  sarcoma.     The  case  cannot  be  traced. 

INOPERABLE  CASES  OF  SARCOMA  OF  THE  JAW 

The  story  and  progress  of  the  cases  of  sarcoma  of  the 
jaw  which  the  surgeon  thinks  are  inoperable  are  most  in- 
teresting. 

Case:  Sick.  A  young  man,  thirty-five  years  old,  for 
ten  months  had  a  swelling  near  to  the  left  tonsil,  inside  the 
mouth.  This  swelling  is  painless.  The  left  half  of  the  soft 
palate  is  thickened  and  appears  gelatinous-like.  At  one 
spot  on  the  soft  palate  over  the  swollen  area  there  is  an  ulcer. 
In  the  left  neck,  at  the  anterior  border  of  the  sternocleido- 
mastoid,  there  is  a  hard  and  smooth  tumor,  4  inches  long, 
unattached  to  the  skin.  The  tumor  is  deeply  adherent.  It 
is  painless.  The  alveolar  border  of  the  lower  jaw  is  en- 
larged, and  this  alveolar  enlargement  is  directly  continu- 
ous with  the  tumor  of  the  neck. 

Microscopic  examination  of  the  tumor  mass  shows  it 
to  be  a  sarcoma;  the  cells  are,  for  the  most  part,  small. 

Case:  McCartney.  A  young  man,  forty-one  years  old, 
for  six  months  has  had  a  swelling  of  the  left  lower  jaw.  The 
tumor  is  rather  hard,  non-sensitive,  smooth  in  outline,  and 
extends  throughout  the  entire  side  of  the  lower  jaw.  The 
swelling  of  the  jaw  is  continuous  with  the  swelling  in  the 
left  temporal  region.  A  bit  removed  from  the  foul,  ulcer- 
ating masses  projecting  from  the  alveolar  border  finds  the 
growth  to  be  an  angiosarcoma. 

The  involvement  of  the  temporal  region  and  the  well- 
established  general  infection  precluded  the  possibility  of 
satisfactory  result  from  operative  interference. 

Case:    Johnson.     A  young  man,  thirty-three  years  old, 
has  had  for  eight  years  a  swelling  upon  the  right  side  of  the 
9 


130  TUMORS   OF   THE    JAWS 

lower  jaw.  He  had  his  tonsil  removed  eight  months  pre- 
viously. There  is  a  large  mass  growing  from  the  hard  and 
soft  palates,  almost  occluding  the  pharyngeal  space.  A 
foul,  ulcerated  surface  is  present.  Talking,  chewing,  swal- 
lowing, and  breathing  are  all  difficult.  There  is  an  inces- 
sant cough. 

Tracheotomy  was  done.  A  bit  of  tumor  tissue  was 
removed,  and  a  microscopic  report  by  W.  F.  Whitney  finds 
it  to  be  a  round-cell  sarcoma.  He  died  about  four  months 
after  he  was  seen  by  a  surgeon,  who  thought  the  case  in- 
operable. 


CEREBRAL  EMBOLISM  FOLLOWING  LIGATION   OF   THE  EXTER- 
NAL CAROTID  ARTERY 

Case  of  Sarcoma  of  the  Superior  Maxilla.  Ligation 
of  the  External  Carotid.  Resection  of  the  Superior 
Maxilla.  Death  from  Cerebral  Embolism. — S.  R.  D., 
a  woman,  fifty  years  old,  married.  Hospital  No.  143635. 
Autopsy  No.  1441.  Massachusetts  General  Hospital 
Records. 

The  patient  had  been  well.  The  climacteric  was  estab- 
lished when  she  was  forty  years  old.  For  some  years  she 
had  had  a  swelling  of  the  soft  parts  of  the  face.  Five  years 
ago  an  operation  had  been  done  for  the  removal  of  this 
tumor  of  the  left  cheek.  Two  years  ago  a  swelling  of  the 
same  cheek  appeared  and  had  increased  gradually  in  size. 
She  had  slight  pain  in  front  of  the  left  ear,  and  at  times 
upon  the  opposite  side  of  the  head.  There  was  a  left 
superior  maxillary  tumor,  hard,  firm,  and  apparently  extend- 
ing from  the  subcutaneous  tissues  into  the  bone.  The 
left  antral  cavity  was  dark  upon  transillumination. 

The  left  external  carotid  was  ligated  just  below  the 
posterior  belly  of  the  digastric  before  the  origin  of  the  facial 
artery.  A  complete  excision  of  the  upper  jaw  was  then 


SARCOMA   OF   THE   JAWS  131 

performed.  The  operation  was  done  in  the  sitting  posture. 
On  the  day  following  the  operation  a  right-sided  hemiplegia 
became  evident.  Six  days  later  she  died,  having  been 
partially  unconscious  from  the  day  following  the  operation 
until  her  death. 


Fig.  112. — Sarcoma  of  the  left  upper  jaw.  Note  swelling  of  the  cheek 
from  the  tumor  within  the  jaw  (see  Figs.  113,  114)  (Massachusetts  General 
Hospital  series). 

Report  Upon  the  Section  of  the  Tumor. — Microscopic 
examination  showed  that  the  tumor  was  composed  of  a 
solid  mass  of  small  round-cells,  having  very  little  protoplasm, 
lying  in  a  fine  fibrous  stroma.  Throughout  the  section 


132 


TUMORS    OF    THE    JAWS 


were  large  numbers  of  thin-walled  blood-vessels.  Diag- 
nosis: Small,  round-cell  sarcoma.  Signed,  W.  F.  Whitney. 
Report  of  the  Autopsy. — Anatomic  Diagnosis:  Operation 
wounds  (removal  of  -tumor  of  the  jaw);  embolism  and 
thrombosis  of  the  left  middle  cerebral  artery,  with  infarction 
involving  the  basal  ganglia;  oedema  pise;  arteriosclerosis 
of  the  aorta;  hypertrophy  and  dilatation  of  the  heart; 
cholelithiasis;  chronic  pelvic  peritonitis. 


Fig.  113. — Under  surface  of  brain. 

The  body  of  a  woman  fifty  years  of  age,  169.5  cm.  long, 
well  developed,  fat. 

Head:  On  the  left  side  of  the  face,  in  the  region  of  the 
left  half  of  the  superior  maxilla,  there  is  a  wound  which 
extends  from  the  malar  bone  over  toward  the  nose,  then 
down  along  the  nose  to  the  region  of  the  median  line  of  the 
upper  lip.  The  wound  is  closed  with  sutures. 

On  section,  the  pia  is  infiltrated  with  a  moderate  amount 
of  pale  fluid.  The  sinuses  are  free,  and  the  middle  ears  are 


SARCOMA    OF    THE    JAWS 


133 


normal.  The  brain  weighs  1 225  gm.  On  section,  the  ventricles 
are  free.  The  internal  carotids  are  free.  The  vessels  leading 
to  the  right  half  of  the  brain  are  not  remarkable.  The  ves- 
sels leading  to  the  left  half  of  the  brain,  with  the  excep- 
tion of  the  middle  cerebral,  are  not  remarkable.  The  left 
middle  cerebral,  a  short  distance  from  its  origin,  is  distinctly 
occluded  by  a  firm,  gray  red,  thrombus-like  mass.  (See  Fig. 


Fig.  114. — Section  of  brain  showing  the  area  of  basal  ganglia  involved. 


113.)  In  some  of  the  first  branches  of  the  middle  cerebral 
the  thrombus  mass  is  apparently  prolonged  as  a  black-red, 
somewhat  softer  material.  In  the  situation  of  the  basal 
ganglia  on  the  left  there  is  a  pale,  in  places  grayish-red, 
disorganized,  more  or  less  disintegrated  soft  mass  of  brain 
tissue,  which  extends  from  the  posterior  portion  of  the  left 
frontal  lobe  back  as  far  as  the  posterior  portion  of  the  left 


134  TUMORS   OF   THE   JAWS 

thalamus  and  including  a  portion  of  the  thalamus  laterally 
and  to  the  left,  and  involving  a  good  half  of  the  striate  body 
and  extending  downward  into  the  temporal  lobe.  (See  Fig. 
114.)  The  condition  extends  into  the  left  temporal  lobe  over 
quite  an  area,  and  reaches  as  far  as  the  cortical  portion.  In 
this  -situation  the  brain  tissue  is  pale,  disintegrated,  and 
mushy.  The  brain  tissue  elsewhere  is  not  remarkable. 
There  is  no  evidence  of  arteriosclerosis  in  the  vessels  of 
Willis. 

Bacteriologic  report:    Cultures  in  blood-serum.     Heart: 
No  growth.     Liver:     No  growth.     Spleen:   No  growth. 
(Signed)     OSCAR  RICHARDSON,  M.D., 
Pathologic  Laboratory, 
Massachusetts  General  Hospital. 

The  facts  of  especial  interest  in  this  case  are  that,  whereas 
the  preliminary  ligation  of  the  external  carotid  was  attended 
with  no  difficulty  at  the  time,  was  quickly  accomplished,  and 
perhaps  prevented  undue  hemorrhage  while  excising  the  jaw, 
yet  subsequently  a  clot  became  dislodged  and  was  carried  by 
the  internal  carotid  into  one  of  the  cerebral  arteries,  causing 
signs  of  partial  unconsciousness  and  hemiplegia  upon  the 
opposite  side,  and  death. 

Figs.  113  and  114  illustrate  well  the  extent  and  the 
gross  appearances  of  the  lesion.  This  deplorable  outcome 
is  to  be  considered  as  possible  in  the  ligation  of  the  exter- 
nal carotid,  although  it  is  comparatively  rare.  Matas  has 
recorded  in  his  wide  experience  3  deaths  from  cerebral 
embolism  following  68  ligations  of  the  external  carotid. 


A    Case    of    Fibrosarcoma    of    the    Upper    Jaw. 

Massachusetts  General  Hospital  series,  vol.  cccli,  p.  208. 
A  man,  forty  years  old.     He  had  noticed  a  small  swelling 


SARCOMA    OF    THE    JAWS 


135 


for  about  seven  months  in  the  region  of  the  first  and  second 
molar  teeth  of  the  upper  jaw.     This  mass  had  been  removed 


B 


Fig.  115. — Fibrosarcoma  of  the  right  upper  jaw.  Complete  resection  of 
right  upper  jaw.  In  A  note  line  of  left  edge  of  palate  in  roof  of  mouth.  In  B 
note  deformity,  with  prosthetic  apparatus  in  situ.  Note  slight  sinking  in 
and  lowering  of  the  right  orbital  contents.  In  C  note  prosthetic  appliance 
used  in  this  case  (Massachusetts  General  Hospital  series). 

and  had  recurred.  In  1899,  when  he  presented  himself  for 
operation,  there  appeared  in  the  roof  of  the  mouth,  on  the 
right  side,  a  ragged,  ulcerating  growth  extending  along  the 


136  TUMORS   OF   THE   JAWS 

alveolar  process  and  involving  it.  A  partial  operation  was 
done,  and  the  bone  beneath  the  tumor  was  removed.  Later, 
in  1900,  a  resection  of  the  upper  jaw  was  done. 

Microscopic  examination  proved  the  growth  to  be  a 
fibrosarcoma. 

Eight  years  subsequently  to  this  operation  the  man  is 
free  from  local  disease  and  in  good  health.  As  is  seen  by 
the  photograph,  he  is  wearing  a  prosthetic  appliance. 

(D)     THE  TREATMENT  OF  SARCOMA  OF  THE  JAWS 

A  proper  consideration  of  the  treatment  of  sarcoma  of 
the  jaws  must  take  into  account  the  kind  of  cell  involved 
in  the  growth,  the  local  extent  of  the  diseased  process,  the 
exact  seat  of  the  disease,  and  the  age  of  the  patient. 

The  exact  surgical  procedure  will  be  either  a  limited 
operation  (inappropriately  called  a  "partial  operation"), 
or  an  extensive  operation.  Obviously,  one  should  avoid 
mutilation  of  the  patient,  and  yet  operate  so  extensively  as 
to  eradicate  the  sarcoma;  and  not  only  should  the  sarcoma 
be  eradicated  without  mutilating  the  individual,  but  this 
should  be  accomplished  with  the  lowest  possible  death-rate. 

With  regard  to  the  kind  of  cell  found  in  the  sarcoma: 
If  the  tumor  is  a  giant-cell  sarcoma,  it  may  occur  centrally 
in  the  bone  or  more  peripherally.  It  has  been  established 
that  the  giant-cell  sarcoma  is  one  of  the  least  malignant 
types  of  sarcoma  (Konig).  Consequently  a  very  extensive 
operation  is  not  necessarily  indicated. 

If  the  giant-cell  sarcoma  is  seated  in  the  lower  jaw,  it 
may  be  possible,  if  some  of  the  bone  still  remains  intact 
along  the  body,  to  curet  and  remove  all  the  growth.  Blood- 
good  and  others  have  advocated  this  procedure,  and  cases 
are  reported  which  make  it  seem  safe. 


SARCOMA    OF    THE    JAWS  137 

If,  on  the  other  hand,  the  bone  is  so  involved  that  it  is 
impossible  to  leave  a  sufficiently  strong  supporting  bonv 
bridge  after  curetage,  it  will  be  wise  to  resect  the  maxilla 
in  continuity.  In  the  case  of  the  giant-cell  sarcoma,  it  will 
be  unnecessary  to  place  the  lines  of  resection  a  long  distance 
from  the  margin  of  the  growth,  because  the  likelihood  of 
recurrence  is  slight. 

If  the  giant-cell  sarcoma  involves  the  upper  jaw,  and,  as 
it  sometimes  does,  fills  the  antrum  and  bulges  the  cheek, 
it  may  be  possible  &o  remove  the  disease  by  a  partial  oper- 
ation. I  am  inclined  to  think,  however,  that  a  complete 
resection  of  the  upper  jaw  under  these  conditions  will  be 
safest.  The  possible  extensions  of  the  growth  in  this  situ- 
ation are  so  many  that  a  complete  removal  by  curetage  alone 
is  almost  a  physical  impossibility.  In  fact,  I  believe  that 
any  malignant  growth,  whether  sarcoma  or  carcinoma, 
involving  and  filling  the  antrum,  is  best  treated  by  excision 
of  the  entire  upper  jaw.  The  removal  of  the  bony  box  of 
the  upper  jaw  uncovers  the  deeper  parts  into  which  the 
malignant  growth  may  have  penetrated. 

If  the  growth  is  a  periosteal  sarcoma  and  is  a  mixed  tumor, 
containing  either  cartilage,  connective  tissue,  bone,  or  myxo- 
matous  tissue,  we  have  to  deal  with  a  relatively  benign 
growth.  It  must  be  remembered,  however,  that  the  sar- 
comatous  element  present  suggests  the  possibility  of  a 
recurrence  of  the  growth  locally.  Moreover,  we  must  not 
lose  sight  of  the  fact  that  if  a  local  recurrence  takes  place, 
the  recurrence  is  liable  to  be  more  malignant  in  its  character 
than  was  the  original  tumor. 

If  the  growth  consists  of  spindle-  or  round-cells,  we 
have  to  deal  with  one  of  the  most  malignant  of  the  sarcomata. 


138  TUMORS   OF   THE   JAWS 

Under  these  circumstances  a  most  radical  and  extensive 
removal  of  the  local  growth  must  be  attempted.  If  the 
malignant  disease  occurs  in  the  antrum,  a  complete  resection 
of  the  upper  jaw  should  be  made,  the  lines  of  section  pass- 
ing through  undoubted  sound  tissue.  All  parts  adjacent 
to  the  diseased  area  should  be  scrutinized  carefully  in  order 
to  detect  any  bits  of  remaining  disease.  I  believe  that  the 
actual  cautery  should  be  applied  to  the  line  of  incision  in 
the  deep  parts,  so  as  to  preclude  the  possibility  of  any  cells 
remaining  undestroyed.  . 

If  the  disease  is  of  the  lower  jaw,  a  complete  resection 
wide  of  the  disease  is  necessary.  Any  glandular  enlarge- 
ments present  in  sarcoma  of  either  the  lower  or  upper  jaw 
should  be  removed.  In  the  absence  of  enlarged  glands  in 
the  least  malignant  forms  of  sarcoma  a  systematic  removal 
of  the  lymphatics  is  not  necessary.  I  believe  that  in  the 
malignant  types  of  sarcoma,  especially  in  the  spindle-  and 
round-cell  sarcomata,  a  systematic  dissection  of  the  neck 
usually  on  both  sides  is  wise. 

Perthes  is  governed  as  to  the  degree  of  operative  removal 
by  the  position  and  the  extent  of  the  growth,  rather  than 
by  its  histologic  characteristics.  I  believe  that  both  the 
histologic  characteristics  and  the  extent  of  the  disease  are 
to  be  considered  in  determining  whether  a  limited  operation 
or  an  extensive  operation  is  to  be  done. 

If  the  disease  is  of  the  less  malignant  type  and  is  seated 
in  the  nasal  cavity,  a  limited  operation  through  an  osteo- 
plastic  flap  may  be  possible.  If  the  disease  is  of  the  less 
malignant  type  and  involves  the  alveolar  process,  the 
limited  operation  may  be  done,  particularly  if  the  disease 
is  in  the  upper  jaw. 


SARCOMA    OF   THE   JAWS  139 

In  general,  one  may  say,  after  limited  operations,  recur- 
rences have  occurred  in  all  types  of  sarcoma.  These  cases 
might  have  avoided  a  recurrence  had  a  primary  extensive 
operation  been  done. 

Konig  limits  a  partial  operation  to  the  upper  jaw. 
Martens  holds  that,  in  dealing  with  malignant  disease  of 
the  upper  jaw,  it  is  not  difficult  to  cut  into  sound  tissue, 
and  one  should  do  a  total  resection,  except  in  cases  of  giant- 
cell  sarcoma,  where  a  partial  operation  is  indicated. 

Perthes  would  do  a  limited  operation  if  the  sarcoma 
were  quite  localized  upon  the  alveolar  process  or  were  of 
the  hard  palate.  In  all  other  cases  he  would  do  a  total 
resection.  Likewise,  if  limited  to  the  alveolar  process  of 
the  lower  jaw,  Perthes  would  do  a  limited  operation. 

There  are  certain  cases  of  the  malignant  sarcomata  in 
which  the  extent  of  the  disease  is  so  great  that  the  very 
extensiveness  of  the  tumor  precludes  the  possibility  of  cure. 
One  must  recognize  that  these  inoperable  cases  exist,  and 
not  attempt,  as  too  often  is  done,  an  extensive  removal  of 
what  experience  has  proved  to  be  irremovable.  Such 
unwarranted  operations  as  these  throw  a  shadow  upon 
surgery.  I  have  seen  a  round-cell  sarcoma  of  the  upper  jaw 
which  has  existed  for  some  time,  and  which  has  filled  the 
antrum,  the  nose,  the  orbit,  ulcerated  the  cheek  and  the 
roof  of  the  mouth — I  have  seen  an  attempt  made  to  remove 
such  a  growth  when  it  was  obvious  that  operative  inter- 
ference was  contraindicated.  Great  harm  is  done  by  such 
meddlesome  surgery.  There  is  no  justification  for  such 
surgery  in  the  statement  that  the  patient  requested  that 
the  operation  should  be  done. 


CHAPTER  III 
BENIGN  TUMORS  OF  THE  JAWS 

CONTENTS  OF  CHAPTER:  Fibroma:  Origin  of  fibroma. — Age  of  occurrence. — 
Varieties  of  fibroma:  Periosteal;  Central. — Etiology. — Symptoms. — 
Diagnosis. — Treatment. — Chondroma  of  the  jaw:  General  observations. 
— Treatment. — -The  Myxoma. — Lipoma. — Osteoma  of  the  jaws:  General 
observations;  Osteoma  of  the  upper  jaw;  Osteoma  of  the  antrum  of 
Highmore;  Hyperplasia  of  superior  maxilla:  Treatment;  Osteoma  of 
the  lower  jaw;  Osteoma  of  the  sinuses  and  the  orbit. 

FIBROMA  OF  THE  JAW 

THE  fibroma  occurs  alike  in  the  upper  and  lower  jaw. 

The  origin  of  the  fibroma  is  somewhat  doubtful.     Virchow 

thought  that  the  fibroma  origi- 
nated from  the  marrow  or  from  the 
bone  itself.  Nimmier  and  Blauel 
think  that  the  fibroma  arises  from 
the  connective  tissue  of  the  peri- 
osteum or  periodontium  or  from 
the  connective  tissue  of  the  blood- 
vessels. 

The  fibroma  is  made  up  of 
dense,  hard  fibrous  tissue,  lobu- 
lated  and  knobbed.  On  section, 
there  may  be  seen  long  and  short 
chains  of  granular  material,  in 
irregular  masses,  constituting  a 
calcification  of  the  fibroma. 

Blauel  records  a  case — the  only 
one  on  record — of  fibroma  which 

in  one  portion  presents  wide  lymph-channels  and  resembles 

a  giant-cell  tumor. 

140 


Fig.  116. — Fibroma  of  the 
upper  jaw.  Man,  twenty  years 
old.  Observed  first  ten  years 
ago.  Two  operations  per- 
formed. Remained  cured  as 
long  as  under  observation — two 
years  (Senn). 


BENIGN    TUMORS    OF    THE    JAWS 


141 


Age  of  Occurrence. — Clinically,  these  tumors  are  benign. 
They  appear  in  middle  life,  most  commonly  during  the  third 
decade.  They  have  been  seen  during  the  second  and  fourth 
decade.  (See  Fig.  116.)  Heath  and  Piscacek  report  a 
case  occurring  in  a  new-born  child.  Perthes  has  seen  a 
case  of  symmetric  tumor  upon  both  upper  jaws,  and  a  case 
symmetric  upon  both  sides  of  the  lower  jaw.  Kritz  records 
a  case  of  symmetric  fibroma  of  the  upper  and  lower  jaws. 


Fig.  117. — Central  fibroma  of  the  under  jaw  (Bauchet,  Perthes). 

These  tumors  may  attain  great  size. 

Varieties  of  Fibroma. — They  may  be  divided  into 
periosteal  and  central  fibromata.  The  periosteal  fibroma 
arises  from  the  periosteum  of  the  jaw,  over  the  alveolar 
process,  from  the  periodontium  lining  the  tooth-socket, 


142 


TUMORS   OF   THE   JAWS 


and  from  the  periosteal  covering  of  the  antrum  of  High- 
more.     Those  cases  arising  from  the  margin  of  the  alveolar 


Fig.  118. — Fibroma  of  the  upper  jaw  in  a  woman  twenty-one  years  old. 
Duration  of  growth,  four  years.  Successful  removal  by  Mr.  Listen.  Xote 
the  appearance  of  the  face  before  and  after  the  removal  of  the  growth.  The 
tumor  might,  from  its  external  appearance,  be  growing  from  the  lower  jaw, 
instead  of  from  the  upper  jaw  (after  C.  Heath). 

process  are  similar  to  the  fibrous  epulis.     The  fibroma  in 

this  situation  is  a  non-vas- 
cular epulis. 

The  central  fibroma  occurs 
most  often  in  the  lower  jaw. 
Several  cases  have  been  re- 
ported by  Schulz,  Kiister, 
and  Zuckerkandl  in  the  upper 
jaw. 
Fig.  119. — Fibroma  of  the  upper  In  the  lower  jaw,  fibroma 

jaw  removed  from  patient  shown  in  .      . ,          .  , 

Fig.  118  (after  C.  Heath).  OCCUrs  most  often  m  the  mid' 

dle  of  the  horizontal  ramus. 
The  tumor  is  surrounded  by  a  shell  of  bone  which  is  a  new 


BENIGN    TUMORS    OF    THE    JAWS 


143 


formation  of  bone  entirely  independent  of  the  jaw  bone 
itself.  The  central  fibroma  may  be  found  free  or  loose  in 
a  fibrous  capsule  made  up  of  several  laminae.  In  the  lower 
jaw  the  tumor  bulges  upon  the  outer  side. 

The  central  fibroma  of  the  upper  jaw  appears  to  start 
in  the  antrum  of  Highmore. 


Fig.  120. — Fibroma  of  the  jaw  of  enormous  size,  removed  successfully  by 
Mr.  Listen  from  a  woman  forty  years  old.  The  tumor  had  existed  for  six 
years  before  it  was  removed  (after  C.  Heath). 

The  etiology  is  unknown.  Broca  and  Blauel  think 
the  fibromata  arise  from  displaced  tooth-buds.  Perthes 
thinks  that  the  absence  of  enamel  and  epithelial  elements, 
which  are  always  characteristic  of  the  odontomata,  lends 
weight  to  the  view  that  these  central  fibromata  are  not 
derived  from  the  tooth-germ. 

Heath  suggests  that  trauma  maybe  an  etiologic  factor. 


144  TUMORS   OF   THE    JAWS 

Bordenaave  believes  that  irritation  of  the  roots  of  decayed 
teeth  may  contribute  to  the  starting  of  a  fibroma. 

They  are  of  very  slow  growth.  Rigaud  notes  one  grow- 
ing twelve  years.  Bauchet's  case  grew  fifteen  years.  Men- 
zel's  case  grew  twenty-five  years. 

They  may  reach  enormous  size.     (See  Figs.  117  and  120.) 


Fig.  121. — -Front  of  the  base  of  the  skull  of  a  patient  with  a  large  fibroma 
of  the  left  side  of  the  lower  jaw.  Note  the  pressure  results  upon  the  upper  jaw, 
and  the  natural  growing  molar  and  zygoma  laterally.  The  patient  died  from 
an  infection  of  the  growth  after  setons  and  incisions  had  been  employed  (after 
C.  Heath). 


The  progress  of  these  tumors   may   be   characterized   by 
periods  of  slow  and  then  by  times  of  rapid  growth. 

The  symptoms  are  those  due  to  pressure  of  the  growth. 
In  the  upper  jaw  pressure  on  the  infra-orbital  nerve  may 
cause  pain.  The  symptoms  from  a  central  fibroma  of  the 
lower  jaw  will  be  those  suggesting  a  benign  slow  growth, 
causing  a  gradual  symmetric  enlargement  of  the  jaw  on 
its  outer  side. 


BENIGN   TUMORS   OF   THE   JAWS  145 

These  tumors  are  benign.  They  never  cause  metastases. 
There  is  no  infiltration  nor  ulceration  associated  with  them. 

Heath  records  a  case  in  which  suppuration  occurred 
because  of  puncture  of  a  fibroma  for  diagnostic  purposes, 

The  x-ray  will  help  in  a  diagnosis  from  growths  likely 
to  be  mistaken  for  it.  If  the  bony  shell  becomes  thinned, 
then  one  may  obtain  a  parchment-like  crepitus  which  may 
be  helpful  in  diagnosis  and  at  times  confusing. 


Fig.  122. — A  central  fibroma  of  the  jaw.     Note  the  expansion  of  the  jaw  by  the 
growth  (University  College  Museum,  London,  after  C.  Heath). 

Treatment  should  be  the  removal  of  the  growth,  with 
the  preservation  of  all  the  bony  support  possible  for  the  jaw. 
A  ridge  should  be  preserved  running  the  whole  length  of  the 
jaw.  Blauel,  Heath,  and  Perthes  insist  upon  keeping  intact 
the  inferior  maxillary  ridge  of  bone,  not  only  as  a  basis  for 
the  permanent  teeth  to  be  fitted  later,  but  for  the  main- 
tenance of  a  symmetric  chin  and  face. 
10 


146  TUMORS   OF   THE   JAWS 

Before  a  radical  removal  of  anatomic  structures  it  will 
be  wise  to  be  positive  as  to  the  diagnosis.  The  removal  of 
a  bit  of  tumor  tissue  for  examination  will  be  helpful. 

CHONDROMA 

The  chondromata  are  rather  rare  growths.  Their 
origin  is  obscure.  Schmidt  thinks  that  they  may  come  from 
cartilage  rests — bits  of  preformed  cartilage. 


Fig.  123.— Osteofibrochondroma.     A  man  forty-four  years  of  age.     Duration 
of  growth,  five  years.     Weight  of  tumor,  3}/£  pounds  (Hingston). 

Berjor's  classification  of  the  chondromata  is  the  best. 
He  arranges  them  in  two  groups — the  benign  and  the  malig- 
nant chondromata. 

The  benign  chondroma  is  composed  of  pure  hyaline 
cartilage,  sometimes  mixed  with  a  little  connective  tissue- 
that  is,  a  fibrochondroma. 


BENIGN    TUMORS    OF    THE    JAWS  147 

The  malignant  chondroma  is  a  mixed  tumor  containing 
not  only  cartilage  tissue,  but  sarcomatous  elements,  and 
possible  bony  elements,  i.  e.,  a  chondrosarcoma  and  an 
osteochondrosarcoma. 

These  tumors  do  not  infiltrate  the  surrounding  parts — 
they  destroy  by  pressure  atrophy.  They  are  contained 
within  a  capsule  of  either  bone  or  connective  tissue. 

The  chondroma  appears  in  early  life,  usually  under 
twenty-five  years,  although  it  may  occur  at  any  age. 


Fig.  124. — Osteofihrochondroma.     Lateral  view  of  same  case  as  Fig.   123. 
Removed   by  operation  successfully    (Kingston). 

The  chondromata  arise  from  both  the  upper  and  lower 
jaws.  The  starting-point  of  these  tumors  is  most  fre- 
quently from  the  alveolar  margin;  next,  from  the  bones  of 
the  face  near  the  orbit,  vault,  and  from  the  palatine  or 
orbital  plates  of  the  superior  maxilla. 

When  arising  from  the  lower  jaw,  the  chondroma  begins 
in  the  body  of  the  bone  centrally  or  peripherally.  It  may 
come  from  the  articular  process,  the  articular  cartilage,  or 
the  coronoid  process. 


148 


TUMORS    OF   THE   JAWS 


The  growth  is  slow.  Cases  have  been  recorded  in  which 
sixteen,  twenty-five,  and  thirty  years  have  been  the  period 
of  growth. 

The  tumor  grows  faster  if  of  the  osteoid  type  or  of  the 
mixed  type  of  chondrosarcoma.  The  size  attained  by  these 
tumors  may  be  very  great. 


Fig.  125. — Same  case  as  Figs.  123  and  124.     Lateral  view  after  operation  for 
.    removal  of  osteofibrochondroma  and  after  plastic  operation  (Kingston). 

A  calcification  of  the  chondroma  may  occur,  and  Heath 
has  recorded  several  instances  of  this  change. 

The  jaw  may  be  involved  secondarily  from  pressure  of 
a  growth  starting  in  a  part  near  the  jaw,  as  when  it  starts 
from  the  orbit. 


BENIGN    TUMORS    OF   THE    JAWS 


149 


Fig.  126.— Craniof  acial  enchondroma. 
Represents  the  appearance  of  the  patient 
full  face.  The  patient  died  during  the 
operation,  because  of  some  respirator}' 
difficulty  (copied  from  a  photograph  by 
H.  G.  Wright.  Recorded  by  Moore. 
Trans.  Path.  Soc.,  vol.  xix,  p.  332). 


Fig.  127.  —  Craniofacial  en- 
chondroma. Represents  the  ap- 
pearance of  the  patient  profile 
view.  Same  case  as  Fig.  126. 


Fig.  128. — Enchondroma  of  right  orbit,  recurrent.  Shows  the  appearance 
of  the  patient  at  the  time  of  his  admission  into  the  hospital.  He  died  of 
pyemia  six  weeks  after  the  operation,  done  in  1868  (Christopher  Heath). 


150 


TUMORS    OF    THE    JAWS 


The  symptoms  are  those  of  pressure.  There  is 
rarely  ulceration  of  the  soft  parts.  The  lymphatics  are  not 
enlarged.  The  distressing  deformity  is  sometimes  terrible. 
Recurrence  of  the  growth  occurs  a  long  time  after  operative 
removal  in  certain  cases.  The  succeeding  recurrences 
become  increasingly  malignant.  Heath  records  such  a  case. 
Lawson  operated  in  one  case  ten  times  in  eighteen  years— 
the  last  recurrence  was  a  spindle-cell  sarcoma. 


A    Case   of    Chondroma   of    the   Upper   Jaw.     Age 
Fifty-one.     (See  Fig.   129.) — Depressed  fracture   of  the 


Fig.  129. — Enchondroma  of  the  upper  jaw.  Man,  fifty-one  years  old. 
Removed  by  successive  operations.  Recurred  (Massachusetts  General  Hos- 
pital series.  Patient  of  C.  B.  Porter). 

nose  at  four  years.  At  eighteen  years  severe  ulceration  of 
the  superior  maxillary  bones  near  the  insertion  of  two 
central  incisor  teeth,  followed  by  necrosis.  Seven  years 
ago  he  had  "congestion  of  the  gums,"  with  swelling  of  the 
lips,  lasting  four  years,  when  a  tumor  appeared. 

First  operation:  Excision  of  anterior  portion  of  both 
superior  maxillse. 


BENIGN   TUMORS   OF   THE   JAWS  151 

Second  operation:  Six  months  later.  Tracheotomy. 
Pharynx  packed  with  gauze.  The  nasal  septum  with  lower 
wall  of  left  orbit  removed. 

He  died  later  of  a  lingering  recurrence. 

Treatment. — Complete  operative  removal  is  necessary. 
Sound  tissue  must  necessarily  be  sectioned  in  its  removal. 
The  complete  removal  of  the  upper  jaw  will  be  necessary 
in  almost  all  cases. 


Fig.  130. — Ostoochondroma   of   the   upper   jaw    (Thompson,  Army   Medica 
Museum.  Washington). 

A  partial  excision  will  be  wise  only  when  there  is  a  dis- 
tinct localization  of  the  tumor,  and  particularly  if  it  is  in 
the  alveolar  process.  I  agree  with  Perthes  in  this  particular. 

THE  MYXOMA 

The  pure  myxoma  is  rare.  A  few  cases  have  been 
recorded.  Myxosarcoma  is  a  more  common  form  than  the 
pure  myxoma. 

The  relatively  flatter  tumor,  of  softer  consistence  and 
of  more  rapid  growth,  is  suggestive  of  the  myxoma. 


152  TUMORS   OF   THE   JAWS 

The  myxomatous  element  indicates  the  necessity  for  a 
more  radical  operation — possibly  for  a  complete  rather  than 
a  partial  operation. 

LIPOMA 

There  are,  according  to  the  note  of  Perthes,  but  three 
cases  of  lipoma  of  the  jaw  recorded. 


Fig.  131. — Osteochondroma  of  the  upper  jaw  (same  case  as  Fig.  130). 
OSTEOMA 

Bony  tumor  may  arise  from  preformed  bone,  cartilage, 
connective  tissue,  or  from  the  periosteum.  Cartilage  has 
been  found  in  an  exostosis  of  the  lower  jaw. 

The  majority  of  cases  appear  in  individuals  before  the 
twentieth  year.  A  certain  number  of  cases  are  bilateral, 
appearing  in  one  jaw  (upper  or  lower)  upon  each  side 
symmetrically.  Symmetry  suggests  a  congenital  origin 
from  rests  of  cartilage. 


BENIGN   TUMORS   OF   THE   JAWS 


153 


Fig.  132. — Osteoma  of  the  upper  jaw.     Note  seat  of  origin  (Vidal,  Heath). 


Fig.  133. — Osteoma  of  the  inner  side  of  the  orbit,  partially  filling  the  orbit 
and  encroaching  upon  the  cranial  cavity,  as  indicated  by  the  dotted  lines 
(Arch.  f.  klin.  Chir.,  vol.  xxvi). 


154 


TUMORS    OF    THE    JAWS 


Fig.  134. — Osteomaof  the  left  orbit.  Removed  successfully.  Man  twenty- 
three  years  of  age.  Typhoid  fever  four  years  previously.  Haziness  of  vision 
in  left  eye.  No  diplopia  present.  Some  pain  in  the  left  forehead  (Deut. 
Zeit.  f.  Chir.,  Bd.  Ixxvii). 


Fig.  135. — Osteoma  of  the  left  orbital  space.  (See  Fig.  134.)  X-ray 
shows  the  solid  bony  tumor.  Arrow  points  to  tumor,  a,  Frontal  sinus;  b, 
incisor  teeth;  c,  sella  turcica. 


BENIGN   TUMORS   OF   THE   JAWS 


155 


Fig.  136. — Osteofibroma  of  the  left  lower  jaw  (Menzel,  Perthes). 


Fig.  137. — Osteoma  of  the  lower  jaw.     A  section  through  the  tumor  (Heidel- 
berg Pathologic  Institute). 


156  TUMORS   OF   THE    JAWS 

The  structure  is  either  that  of  a  spongy  bone  or  of  a 
sclerotic,  hard  bone. 

Osteoma  of  the  Upper  Jaw. — It  will  be  attached  by 
a  narrow  or  a  broad  base.  It  often  appears  in  the  anterior 
wall  of  the  antrum,  above  the  canine  fossa.  The  deformity 


Fig.  138. — Exostosis  osteomaof  the  articular  process  of  the  lower  jaw  (Eckert, 

Bruns,  Perthes). 

and  the  interference  with  the  mouth  and  movements  of  the 
jaw  are  the  sole  signs.     (See  Fig.  132.) 

Osteoma  of  the  Antrum  of  Highmore. — It  is  a  rare 
tumor.  It  may  be  pedunculated  or  free  in  the  antrum. 
The  tumor  may  break  through  to  the  orbit,  antrum,  or 


BENIGN   TUMORS   OF   THE   JAWS  157 


Fig.  139. — Osteoma  of  the  lower  jaw  of  an  old  woman  (Volkmann,  Perthes). 


Fig.  140. — Lower  jaw  of  an  adult.  A  rounded,  pedunculated  osteoma 
arising  from  the  body  of  the  jaw,  beneath  the  canine  and  bicuspid  teeth,  which 
are  intact  (Warren  Museum,  No.  1461). 


158 


TUMORS    OF    THE    JAWS 


cranial  cavity.     The  etiology  is  uncertain.     Infection  may 
occur  from  the  nose. 

Cases  of  localized  hyperplasia  of  the  superior  maxilla 
have  been  described  and    reported    by  Westmacott    and 


Fig.  141. — Bony  enlargement,  osteoma  of  alveolar  process  of  jaw  in  a  woman 
thirty-three  years  old  (Warren  Museum,  No.  4836). 


Fig.  142. — Bony  enlargement  of  alveolar  process  of  jaw.  Duration,  six 
or  seven  years.  Never  any  pain.  Mucous  membrane  unbroken  (Bigelow, 
Warren  Museum,  No.  4836). 

Southam,   Manchester,   England.      (See   Figs.    143-147  in- 
clusive.) 

This  hyperplasia  of  the  superior  maxilla  is  very  much 


BENIGN    TUMORS    OF   THE    JAWS 


159 


like  a  hyperostosis.     It  may  be  associated  with  carious  teeth. 
It  affects  both  sides  of  the  alveolar    arch.     It  progresses 


Fig.  143. — The  alveolus  of  a 
normal  jaw,  for  comparison  with 
the  accompanying  plates  (see  Figs. 
144,  145,  and  146)  (Westmacott). 


Fig.  145. — The  alveolar  process 
of  an  upper  jaw  of  a  girl  of  nineteen 
years  who  had  received  a  blow  upon 
the  jaw  nine  years  previously.  The 
entire  upper  jaw  excepting  the  or- 
bital portion  was  excised  for  pain 
and  disfigurement.  There  has  been 
no  recurrence  (Westmacott). 


Fig.  144. — Superior  surface  of 
maxilla  excised,  showing  the  antral 
cavity  filled  with  cancellous  bone 

(Westmacott). 


Fig.  146. — A  cast  of  the  alveolar 
process  of  the  upper  jaw  of  a  girl  of  nine- 
teen years  who  had  had  pain  in  the 
posterior  teeth  of  this  jaw  in  the  region 
of  the  tumor  indicated  in  the  figure. 
The  tumor  tissue  was  removed,  and 
proved  to  be  vascular  bone  of  rather 
soft  consistence  (Westmacott). 


toward  the  outer  wall  of  the  superior  maxilla.  The  deform- 
ity and  the  neuralgic  pain  lead  the  patient  with  this  disease 
to  consult  the  dentist  or  physician. 


160  TUMORS    OF   THE   JAWS 

The  x-ray  will  assist  in  the  diagnosis. 

A  partial  operation  may  be  all  that  is  necessary.  The 
removal  of  the  shell  of  bone  over  the  tumor,  with  its  enuclea- 
tion,  may  be  the  best  procedure. 

Osteoma  of  the  Lower  Jaw. — Almost  any  part  of  the 
lower  jaw  may  be  the  seat  of  an  osteoma. 

Osteoma  of  the  Sinuses  and  the  Orbit. — The  ivory- 
like  osteomata  sometimes  originate  in  the  sinuses  of  the 


Fig.  147. — A  cast  of  the  alveolus  of  an  upper  jaw  of  a  woman  of  thirty 
years.  The  enlargement  progressed  for  four  years.  Carious  teeth  existed, 
and  occasional  pain  was  felt  (Westmacott) . 


nose  and  frontal  and  sphenoid  cells,  or  in  the  orbit  itself. 
(See  Figs.  133  and  134.)  These  orbital  or  sinus  osteomata 
progress  slowly.  They  cause  symptoms  because  of  their 
slow  but  irresistible  progress. 

Borhaupt  has  described  the  collected  cases  of  orbital 
osteomata — some  57  altogether. 

These  tumors  probably  arise  from  the  wall  of  the  orbit 
or  from  some  sinus  of  the  nose,  and  are  most  often  circum- 


BENIGN   TUMORS   OF   THE   JAWS  161 

scribed,  surrounded  by  a  fibrous  or  bony  capsule,  although 
they  may  be  without  encapsulation. 

There  are  about  49  cases  of  encapsulated  orbital  osteo- 
mata  recorded: 

23  cases  originated  from  the  frontal  sinus. 
11  cases  originated  from  the  ethmoid  cells. 
10  cases  originated  from  the  antrum  of  Highmore. 
5  cases  originated  from  the  sphenoid  cells. 


11 


CHAPTER  IV 
THE  ODONTOMATA 

CONTENTS  OF  CHAPTER:  Definition. — Classification. — Normal  development 
of  the  teeth.— The  development  of  the  hair — analogy. — Normal  adult  tooth. 
— Epithelial  cord. — The  papilla.— The  enamel  organ. — The  follicle. — 
The  jaw  and  the  tooth. — Epithelial  rests. — Paradental  epithelial  debris. — 
Adamantine  epithelioma:  Origin;  Clinical  course;  Synonyms;  Age  of 
appearance;  Sex  relationship;  Jaw  involved;  Progress  of  the  growth: 
Size;  Rate  of  growth;  Relation  to  the  jaw  itself;  Character  of  mucous 
membrane;  Lymphatic  glands;  Tabulated  characteristics  of  the  adaman- 
tine epithelial  tumor;  Relation  to  dentigerous  cyst;  Differentiation  from 
an  epulis;  Differentiation  from  a  dentigerous  cyst;  Differentiation  from 
a  carcinoma;  Differentiation  from  a  sarcoma;  Pathology  of  adamantine 
epithelial  tumor;  Gross  pathology;  Microscopic  pathology;  Treatment; 
Prognosis. — Cysts  of  the  jaw:  Dentigerous  cysts;  Origin;  Growth:  L'pper 
jaw;  Etiology;  Pathology;  Walls  of  cyst;  Contents  of  cyst ;  Multilocular 
cysts:  Diagnosis;  Treatment;  Compound  follicular  odontomata;  Dental 
cysts;  Root-cysts;  Symptoms;  Differential  diagnosis;  Treatment;  The 
hard  odontoma. 

THE  DEVELOPMENT  OF  THE  TEETH 

Definition. — An  odontoma  is  a  tumor  of  the  jaw  arising 
from  a  portion  of  a  tooth's  follicle.  The  particular  histo- 
logic  characteristics  of  the  tumor  are  determined  by  the 
stage  of  development  of  those  cells  of  the  follicle  from  which 
the  tumor  originates.  The  follicle  is  the  whole  tooth-germ. 

Many  classifications  of  the  odontomata  have  been  made. 
The  most  satisfactory  is  that  of  Bland-Sutton,  on  an  embry- 
ologic  basis.  All  the  varieties  there  included  are  too  num- 
erous for  the  convenience  of  the  surgeon.  Several  of  the 
tumors  in  Bland-Sutton's  list  occur  so  infrequently  that, 
for  practical  purposes,  they  may  be  omitted. 

The  following  varieties  of  odontomata  are  of  surgical 
importance : 

162 


THE    ODONTOMATA 


163 


1.  The  dental  root-cyst. 

2.  The  follicular  or  dentigerous  cyst. 

3.  The  compound  or  composite  follicular  cyst. 

4.  The  adamantine  epithelioma. 

5.  The  hard  odontoma. 

THE  NORMAL  DEVELOPMENT  OF  THE  TEETH 
In  order  to  have  an  understanding  of  the  nature  of  the 
odontomata  it  is  necessary  to  have  a  very  accurate  knowl- 
edge of  the  normal  development  of  the  teeth. 


Fig.  148. — Section  of  jaw  of  rabbit 
embryo,  showing  dental  ridge  cut 
across:  ec,  Oral  epithelium;  e,  epi- 
thelial outgrowth  corresponding  to 
future  enamel  organ;  m,  mesoblastic 
tissue  (Marshall's  "Operative  Den- 
tistry"). 


Fig.  149. — First  rudiments  of  a 
hair  from  the  human  embryo  of  six- 
teen weeks:  a,  b,  layers  of  cuticle; 
m,  m,  cells  of  the  rudimentary  hair; 
i,  hyaline  envelop  (Marshall's  "Opera- 
tive Dentistry"). 


In  the  development  of  the  teeth  there  is  an  analogy  to 
the  development  of  the  hair.  The  first  signs  of  both  hair 
and  teeth  are  seen  in  the  changes  occurring  in  the  lower  or 
malpighian  epithelial  layer.  The  deeper  cells  of  the  mal- 
pighian  layer  grow  into  the  tissue  beneath.  In  the  case  of 
the  teeth  the  malpighian  cells  crossing  the  rudimentary 
alveolar  processes  dip  into  the  mesoderm.  The  part  of  the 
malpighian  layer  dipping  into  the  mesoderm  is  called  the 
epithelial  cord  or  bud.  (See  Figs.  148,  149,  and  150.) 


Fig.  150. — Vertical  section  of  the  skin,  showing  bulbous  ends  of  two  hairs 
(X  55)  (Marshall's  "Operative  Dentistry"). 


Enamel  o: 
before  im 

nation 


Fig.  151. — Lower  jaw  of  human  embryo,  ninth  to  tenth  week  (X  80)  (Mar- 
shall's "Operative  Dentistry"). 
164 


THE    ODONTOMATA 


165 


The  likeness  in  the  development  of  the  tooth  and  hair  may 
be  still  further  seen  in  the  formation  of  the  papilla  and  the 
invagination,  by  the  growing  into  it  of  the  flask-shaped 
epithelial  malpighian  cord.  (See  Fig.  150.) 


Budding  of  the 
primitive  epi- 
thelial cord 


Primitive 
epithelial  cord 


Enamel  organ 
Dentin  papilla 


Fig.  152. — Vertical  section  of  cuspid  of  human  fetus,  showing  the  budding  of 
the  primitive  epithelial  cord  (X  70)  (Marshall's  "Operative  Dentistry"). 


The  epithelial  cord  (see  Figs.  152  and  153)  sends  off  a 
bud  or  process  called  the  epithelial  lamina.  The  epithelial 
lamina  occupies  a  horizontal  position  to  the  epithelial  cord 
in  the  lingual  side  of  the  jaw.  It  is  from  this  lamina  or 
lateral  process  that  the  permanent  teeth  are  derived. 


166 


TUMORS    OF    THE    JAWS 


A  section  of  the  normal  adult  tooth  (see  Fig.  154)  shows 
well  the  various  completed  portions  of  the  tooth  structure. 


Dental  ridgt 


Epithelial  lamina 


;-s* 
- 


Polyhedral 

'  flatter 

epithelial  c 


^  Club-shaped  e 
'arjrenient  of  i 
thelial  con 


153. — Vertical  section  of  epithelial  cord,  or  primitive  enamel  organ  ( X  300) 
(Marshall's  "Operative  Dentistry"). 


It  is  important  to  be  mindful  of  the  enamel,  the  dentin, 
the  pulp  chamber,  and  the  cement. 

The  epithelial  cord  in  its  growth  dips  deeper  and  deeper 
into  the  cells  of  the  rudimentary  jaw,  and  forms  the  primi- 


THE    ODONTOMATA 


167 


tive  enamel  organ  (see  Fig.  155)  of  the  tooth.  The  enamel 
organ  enlarges  and  becomes  more  club-shaped. 

The  papilla  grows  into  and  invaginates  the  enamel 
organ  opposite  it  by  the  increase  of  its  mesoblastic  cells. 
(See  Fig.  155.) 

There  is  an  enamel  organ  for  each  tooth.  There  is  a 
papilla  opposite  to  and  corresponding  to  each  enamel  organ. 


Fig.    154. — Showing  structures   of   a   tooth:    1,  Enamel;    2,  cementum;    3, 
dentin;  4,  pulp-chamber  (Marshall's  "Operative  Dentistry"). 


The  enamel  organ,  derived  from  the  ectoderm,  epithelial 
in  character,  determines  the  form  of  the  future  tooth.  (See 
Fig.  156.)  The  papilla,  derived  from  the  mesoderm,  con- 
nective tissue  in  character,  fills  out  the  form  of  the  tooth 
determined  by  the  enamel  organ.  The  papilla  produces 
the  future  dentin,  cement,  and  tooth-pulp.  (See  Figs.  155 
and  156.) 


168 


TUMORS    OF    THE    JAWS 


The  sac  of  the  tooth  forms  from  the  connective-tissue 
cells  about,  and  completely  surrounds,  the  papilla  and  the 
enamel  organ.  (See  Figs.  155,  156  and  157.)  The  enamel 


Primary  epithelial  cord 


Dentin  papillae 


Bud  to  form  the 
M-condary  epi- 
thelial cord 

Knamel  onran 


Fig.  155. — Evolution  of  dental  follicle  at  about  the  ninth  week,  showing  in- 
vagination  of  enamel  organ  (X  70)  (Marshall's  "Operative  Dentistry"). 


organ,  the  dentin  papilla,  and  the  sac  altogether  form  the 
tooth-follicle. 

The  enamel  organ,  proceeding  downward  over  the  up- 
ward growing  papilla,  soon  completely  surrounds  the  papilla 


THE    ODONTOMATA 


169 


as  if  by  a  hood.     The  hood  of  the   enamel   organ  has  a 
double  wall. 

Fig.  156  shows  beautifully  the  follicle  completed,  the 
epithelial  cord  separated,  and  the  two  sets  of  teeth,  tem- 
porary and  permanent,  in  the  jaw. 


Fig.  156. — Section  of  human  developing  tooth,  showing  the  follicle  closed 
and  the  primary  epithelial  cord  severed  from  its  enamel  organ  (Marshall's 
"Operative  Dentistry"). 

This  hood  or  double-wall  enamel  membrane  has,  there- 
fore, an  inner  and  an  outer  layer.  The  inner  enamel-cells 
are  tall  and  cylindric  (ameloblastic  layer) ;  the  outer  enamel - 
cells  are  flat  and  cubical.  (See  Figs.  160  and  161.) 

The  space  between  the  two  membranes  or  walls  of  the 
enamel  hood  is  filled  with  a  meshy,  cellular  enamel  pulp 
or  stellate  reticulum.  (See  Figs.  160  and  161.) 


170 


TUMORS    OF    THE    JAWS 


Just  beyond  the  ameloblastic  cylindric  cells  is  an  inter- 
mediate layer — the  stratum  intermedium.  (See  Fig.  159.) 

Fig.  158  shows  beautifully  in  the  higher  power  the  cells 
of  the  several  layers  of  the  developing  follicle. 

The  Jaw  and  the  Tooth. — There  is  often  a  haze  of 
misapprehension  concerning  the  exact  structure  of  a  part 


Odontoblasts 


Sac-wall 


Sac-wall 


Fig.  157. — Developing  human  cuspid  (Marshall's  "Operative  Dentistry"). 

where  two  somewhat  different  tissues  unite.  The  tooth- 
socket  and  the  alveolar  border  are  two  such  regions.  Fig. 
163  shows  well  the  normal  relation  between  the  bony  wall 
of  the  tooth-socket  and  the  contained  tooth-root.  The 
alveolar  border  and  its  relations  to  the  gum  and  the  tooth 
are  well  shown  in  Fig.  162. 


THE    ODONTOMATA 


171 


The  alveolo-dental  periosteum  is  a  fibrous,  connective- 
tissue  structure  which  covers  the  root  of  the  tooth  and  the 
walls  of  the  alveoli  or  tooth-sockets,  and  is  continuous  with 
the  periosteum  of  the  alveolar  border.  (See  Fig.  162.)  It- 
is  from  this  tissue  that  the  ordinary  form  of  epulis  arises. 
(See  Chapter  I.) 


Stellate  reticulum 


Ameloblastic 
laver 


Formed  enamel 


Truncated  ends 
of  odontoblasts 


Formed  dentin 


Odontoblastic 
layer 


Dental  papillae 


Fig.  158. — Section  of  tooth-follicle  (human),  showing  the  nuclei  of  the 
odontoblasts  and  of  the  ameloblasts,  and  the  truncated  ends  of  these  cells 
(V.  C.  Latham)  (X  325)  (Marshall's  "Operative  Dentistry"). 

As  the  tooth  grows  its  root,  which  is  made  up  of  four 
layers  of  cells,  viz.,  the  inner  enamel  epithelium,  an  inter- 
mediary layer,  the  enamel  pulp,  an  outer  enamel  epithelium 
(see  Fig.  163),  tapers  off  into  the  part  containing  it  and  dis- 
appears. The  enamel-cells  down  in  the  root  cease  to  form 
enamel.  Certain  groups  of  these  epithelial  cells  may  remain 


172 


TUMORS   OF   THE   JAWS 


in  the  embryonic  jaw,  and  are  known  as  cell-rests  or  epithelial 
rests. 

Malassez  first  directed  attention  to  the  significance  of 
these  tooth  epithelial  rests.  He  called  them  the  paradental 
epithelial  debris.  He  thought  that  their  origin  was  from 


Formed  dentin 


Odontoblasts 


Pulp 


Fig.  159. — Section  of  developing  human  tooth,  showing  amelobhists 
highly  magnified  (Zeiss  one-twelfth  oil-immersion)  (Marshall's  "Operative 
Dentistry"). 


one  of  three  sources  in  fetal  life:  (1)  From  the  mucous 
membrane  of  the  fetal  jaw;  (2)  from  the  epithelial  cord  or 
lamina  between  the  mucous  membrane  and  the  enamel 
organ;  or  (3)  from  the  outer  epithelial  membrane  of  the 
enamel  organ  itself  about  the  tooth-root  already  mentioned. 


THE    ODONTOMATA 


173 


Malassez  is  evidently  correct  in  his  interpretation  of 
the  importance  of  these  epithelial  rests. 

ADAMANTINE  EPITHELIOMA 

Origin. — The  adamantine  epitheliomata  arise  from  the 
epithelial  rests  or  paradental  epithelial  debris  (Malassez). 


Ameloblastic  layer 
and  ameloblastic 

processes 


Stellate  reticulum 


Forming  dentin 


Dental  papillse 


Fig.  160. — Transverse  section  of  dental  follicle,  showing  first  layer  of  amelo- 
blasts  (V.  A.  Latham)  (X  325)  (Marshall's  "Operative  Dentistry"). 

Certain  cells  of  the  enamel  organ  (see  Figs.  156,  157,  and 
158)  develop  erratically,  forming  later,  by  their  development, 
this  tumor  or  new-growth. 


174 


TUMORS    OF    THE    JAWS 


There  is  very  great  likelihood  that  the  cells  of  the 
primary  epithelial  cord  (see  Fig.  156),  having  served  their 
usefulness,  are  detached  from  the  original  enamel  organ 
cells,  and  may  be  the  cells  which,  persisting,  form  the  tumor 
under  consideration. 

This  now  generally  accepted  theory  of  the  origin  of 
these  tumors  explains  the  appearance  of  tumors  of  this 


Stellate  reticulum 


Stellate  reticulum 


Masses  of 
calcoglqbulin  _ 
in  calcifying  Vjgjl 
ameloblasts   ™ 


Outer  ameloblastic 
membrane 

Inner  ameloblastic 
membrane 


Stratum  intermedium 
Calcifying  enamel 


Dentin 
Pulp 


Fig.  161. — Developing  tooth  of  embryo  lamb  (after  Andrews)  (X  105)  (Mar- 
shall's "Operative  Dentistry"). 

character  within  the  body  of  the  jaw,  away  from  the  surface 
epithelium,  the  cells,  as  rests,  being  included  in  the  marrow- 
spaces  of  the  bone. 

This  theory  also  explains  the  occurrence  of  tumors  of 
this  type  more  or  less  independent  of  the  teeth.  Inflamma- 
tory processes  in  the  jaws  and  traumatisms  are  of  very 
uncertain  etiologic  importance  as  primary  conditions. 
They  are  only  of  secondary  importance. 


THE    ODONTOMATA 


175 


SYNONYMS. — Epithelial  odontoma;   adamantine  epithe- 
lial  tumor;    adamantlnoma ;    cystic   carcinoma;    adenosar- 


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Fig.  162. — Longitudinal  section  of  root  of  tooth  in  situ,  showing  relation 
of  the  tissues  and  Sharpey's  fibers  in  the  alveolar  process  (F.  B.  Noyes) :  D, 
Dentin;  AT,  Nasmyth's  membrane;  C,  C,  cementum;  F,  fibers  supporting 
gingivus;  F1,  fibers  joining  the  outer  layer  of  periosteum  over  the  alveolar 
process  (Sharpey's  fibers);  F2,  fibers  running  from  cementum  to  bone;  B, 
bone  or  alveolar  process  (Marshall's  "Operative  Dentistry"). 

coma;  adenocarcinoma ;  multilocular  dentigerous  cyst;  cyst- 
adenoma  of  the  jaw. 


176 


TUMORS    OF    THE    JAWS 


Clinical  Course. — The  adamantine  epithelioma  is  one  of 
the  forms  of  the  odontomata.  It  is  not  an  uncommon  growth. 
It  is  seen  almost  as  often  as  is  the  benign  dentigerous  cyst. 

It  takes  its  origin  from  embryologic  epithelial  remains 


Alveolar  process  - 


Cancel  lus  ~ 


larpey's  fibers 


Alveolar  process 


Cancellus 


Pericemeiitum 


C'ernriiHim 


Dcntin 


Fig.  163. — Vertical  section  of  human  alveolar  process  and  cuspid  tooth  in  .*//«. 
(V.  A.  Latham)  (XlOO)  (Marshall's  "Operative  Dentistry"). 

of  the  tooth-germ, — from  the  enamel  organ, — hence  its 
name,  adamantine  epithelioma.  (See  Figs.  153, 155,  and  158.) 
It  is  the  most  benign  form  of  an  epithelial  tumor  of  the 
jaw.  This  tumor  appears  in  young  adults,  that  is,  between 
the  ages  of  twenty  and  forty.  It  is  rarely  seen  during  the 


THE    ODONTOMATA 


177 


age  of  the  milk-teeth,  nor  does  it  often  develop  in  old  age. 
The  age  of  the  youngest  case  recognized  and  recorded  is 
eight  years.  The  age  of  the  oldest  case  reported  is  sixty- 
one  years.  It  may  start  after  the  pulling  of  a  tooth  as  a 
swelling  in  the  gum.  The  pulling  of  a  tooth  may  be  at- 
tended with  the  escape  of  a  thin,  brown,  odorless  fluid,  the 
contents  of  a  cystic  cavity. 


Fig.  164. — Case  of  adamantine  epithelial  tumor  of  the  lower  jaw  (author's 
case).     (See  Fig.  165.) 

Sex  Relationship. — The  adamantine  epithelioma  occurs 
with  about  twice  as  great  frequency  in  females  as  in  males. 
Sex  is  of  little  importance  as  an  etiologic  factor. 

Situation. — It  occupies  most  frequently  the  lower  jaw, 
near  the  angle — the  region  of  the  molar  teeth.  A  very 
few  cases  are  recorded  in  the  upper  jaw.  Albarran  and 
Bloodgood  each  mention  one  case. 

12 


178 


TUMORS    OF    THE    JAWS 


It  is  situated  not  only  in  the  lower  jaw,  but  usually  on 
one  side  of  the  lower  jaw.  In  its  growth,  starting  from  the 
alveolar  border,  it  may  project  from  that  border  as  a  distinct 
tumor.  It  may  start  within  the  body  of  the  jaw,  and 
enlarge  upward  toward  the  temporomaxillary  articulation, 


Fig.  165. — Case  of  adamantine  epithelioma  and  dentigerous  cyst  of  the 
lower  jaw.  Gross  spe  jimen.  Arrow  points  to  the  mucous  membrane  covering 
the  alveolar  process  over  the  tumor  of  the  lower  jaw.  Recovery.  No  re- 
currence (author's  case)  (W.  F.  Whitney,  pathologist). 

and  forward  toward  the  symphysis  of  the  jaw,  expanding  the 
jaw  as  it  grows,  creating  a  tumor 'with  thin  bony  walls. 

If  the  growth  begins  in  the  upper  jaw,  it  will  be  very 
likely  to  expand  into  the  antrum  until  the  antrum  is  filled 
by  the  growth.  No  tumor  will  appear  until  the  antrum  is 
filled.  The  eyeball  under  these  circumstances  is  not  much 
displaced. 


Fig.  166. — Adamantine  epithelioma  and  dentigerous  cyst  of  the  lower 
jaw.  Section  of  the  tumor.  Note  the  cystic  character  and  notice  the  solid 
portion  of  the  tumor — the  adamantine  cells  were  found  in  this  portion. 
Recovery.  No  recurrence  (author's  case)  (W.  F.  Whitney,  pathologist). 


Fig.   167.— Ca.se     of  adamantine  Fig.    168.— Case    of  adamantine 

epithelial  tumor  after  operation.  Note  epithelial  tumor  after  operation.  Note 
the  median  lip  and  chin  portion  of  the  the  posterior  portion  of  the  line  of  the 
incision.  (See  Figs.  165  and  166.)  incision. 

179 


180 


TUMORS    OF    THE    JAWS 


Size. — The  adamantine  epithelial  tumor  varies  in  size.  It 
may  be  recognized  when  as  small  as  a  walnut.  It  may 
grow  to  the  size  of  a  grape-fruit  or  an  orange.  It  may 
attain  a  very  great  size.  (See  Figs.  174,  175.) 

Rate  of  Growth. — Although  these  tumors  are  usually  of 
slow  growth,  they  may  increase  in  size  with  considerable 


Fig.  169.  Fig.  170. 

Figs.  169  and  170. — Case  of  adamantine  epithelioma  of  the  lower  jaw  (Massa- 
chusetts General  Hospital  series). 

rapidity.  The  tumor  growth  may,  therefore,  be  said  to  be 
variable.  A  sudden  increase  in  size  may  be  without  appar- 
ent reason.  Pain  will  be  dependent  upon  the  rapidity  of 
the  growth  or  the  presence  of  an  infection.  A  very  rapidly 
growing  tumor  will  cause  pain  by  direct  pressure  upon 
nerve-trunks. 

Relation  to  Jaw. — The  adamantine  epithelial  tumor  is 


THE    ODONTOMATA  181 

fixed  and  intimately  connected  with  the  jaw — immovable. 
The  tumor  may  extend  from  the  angle  of  the  jaw  quite  to 
the  symphysis.  The  surface  of  the  tumor  is  slightly  irregu- 
lar. This  irregularity  of  the  surface  is  due  to  the  cystic 


Fig.  171. — X-ray  of  tumor  previous  to  operation.     Clinical  appearance  seen 
in  Figs.  169  and  170. 

and  solid  character  of  the  growth.     The  growth  may  be 
wholly  solid  or  cystic  or  both  solid  and  cystic. 

Character  of  Mucous  Membrane, — The  mucous  membrane 
covering  the  tumor  is  usually  normal  in  appearance,  without 
signs  of  ulceration.  If  an  infection  of  the  growth  occurs, 
fistulse  may  result,  communicating  with  the  cystic  interior 
of  the  tumor  and  with  the  mouth.  The  lymphatic  glands 


182 


TUMORS    OF   THE   JAWS 


are  not  enlarged.     In  the  presence  of  an  infection  of  the 
growth  the  lymphatic  glands  of  the  neck  will  appear  enlarged. 


Case  of  Adamantine  Tumor  of  Jaw. — A.  G.  C.  Female, 
twenty-three  years  old.  Married.  Massachusetts  General 
Hospital  Record,  vol.  ccclxxxii,  p.  28.  (See  Figs.  169,  170.) 


Fig.  172. — Section  of  Fig.  171.     Dentigerous  cyst.      Adamantine  epithelioma. 
Sarcoma  (J.  C.  Warren). 

Four  years  ago  was  troubled  by  an  ulcerated  tooth. 
Many  teeth  of  the  lower  jaw  were  removed.  Four  months 
ago  a  lump  appeared  upon  the  inside  of  the  jaw.  It  opened 
and  discharged.  Since  that  time  there  has  been  a  gradual 
increase  in  the  size  of  the  lump.  Two  years  ago  the  swell- 
ing of  the  lower  jaw  appeared,  as  seen  in  the  accompanying 
illustrations  (Figs.  169  and  170).  An  operation  was  done 
at  this  time  for  the  removal  of  the  tumor  and  excision  of 
the  left  half  of  the  lower  jaw.  The  glands  of  the  neck  were 
removed. 


THE    ODONTOMATA 


183 


Pathologic  report  (see  Figs.  172,  173) :  A  mass  the  size 
of  an  infant's  fist  growing  in  the  jaw,  which  was  distended 
over  it.  The  mass  was  covered  in  places  with  a  thick  shell 
of  bone;  in  other  places  by  a  thin,  parchment-like  cover- 
ing of  bone.  The  cavity  in  the  bone  was  lined  with  a  distinct 
sac,  and  between  the  sac  and  the  tumor  was  a  cavity  con- 
taining a  little  serous  fluid.  Upon  section  the  surface  appears 


Fig.    173. — Dentigerous   cyst.      Adamantine    epithelioma. 

Figs.  169,  170.) 


Sarcoma.     (See 


gray,  opaque,  and  homogeneous,  with  extensive  areas  of  fatty 
degeneration  throughout. 

Microscopic  examination  showed  a  fibrous  tissue  stroma 
in  places,  with  large  meshes,  filled,  apparently,  with  a  serous 
fluid;  in  other  places  the  basic  substance  was  more  uniform, 
and  there  were  present  large  round-cells  in  great  numbers. 
Blood-vessels  were  present  in  the  growth,  some  with  well- 
marked  walls  and  others  with  sinus-like  openings.  Scat- 


184  TUMORS   OF   THE   JAWS 

tered  throughout  the  basic  substance  was  a  solid  mass  of 
cells  of  a  character  resembling  epithelium.  These,  in  places, 
had  a  central  opening,  or  lumen,  giving  the  impression  of  a 
more  or  less  irregular,  tubular,  glandular  growth  in  the  midst 
of  the  basic  tissue.  Diagnosis:  Sarcomatous-like  den- 
tigerous  cyst  and  adamantine  epithelioma  tissue  (W.  F. 
Whitney,  pathologist). 

At  the  end  of  two  years  the  patient  was  in  good  condi- 
tion, and  there  has  been  no  recurrence  of  the  disease. 


If  the  tumor,  or  any  part  of  it,  ruptures  into  the  mouth, 
the  growth  of  the  tumor  often  ceases.  Pressure  upon  the 
surface  of  the  tumor  may  elicit  from  the  thin  bony  cover- 
ing a  parchment-like,  crackling  sound. 

The  following  are  the  characteristics  of  an  adamantine 
epithelioma:  A  tumor  of  slow  growth,  in  a  young  adult; 
affects  the  lower  jaw;  starts  from  the  periphery,  sometimes 
from  the  center  of  the  jaw;  no  ulceration  over  its  surface; 
of  considerable  size;  variable  growth;  no  glandular  enlarge- 
ments; occupies  one  side  of  the  jaw,  rarely  in  the  midline; 
solid  and  cystic;  of  rather  irregular  outline,  with  a  surface 
which  crackles  upon  palpation ;  teeth  near  the  tumor  more 
or  less  irregular  and  often  loose. 

Relation  to  the  Dentigerous  Cyst. — The  slow  growth  of 
the  adamantine  epithelial  tumor  differentiates  it  from  the 
malignant  tumors  of  the  jaw.  It  may  grow  for  many  years 
(twenty)  before  operative  relief  is  sought.  So  commonly 
is  the  dentigerous  cyst  found  in  combination  with  the 
adamantine  epithelioma  that  it  may  be  difficult  to  distin- 
guish between  a  simple  dentigerous  cyst  and  a  combination 
growth  until  the  cross-section  of  the  tumor  is  made.  (See 


THE    ODONTOMATA 


185 


Fig.  172.)  In  those  instances  where  no  cyst  is  found  it  is 
quite  possible  that  the  epithelial  element  in  the  growth  has 
completely  filled  all  the  dentigerous  cystic  cavities. 

These  tumors,  at  their  beginning,  cannot  easily  be  mis- 
taken for  an  epulis,  for  the  mucous  membrane  covering 


Fig.  174. — Adamantine  epithelioma  of  the  upper  jaw.  Woman  aged 
fifty  years.  Duration,  ten  years.  Operation.  Death  (Halsted  and  Blood- 
good). 

them  remains  intact,  whereas  the  surface  covering  a  large 
epulis  is  usually  ulcerated. 

When  the  adamantine  epithelial  tumor  starts  in  the 
center  of  the  bone  and  expands  the  bone,  it  is  difficult  to 
distinguish  it  from  a  dentigerous  cyst.  After  section  of  the 


186 


TUMORS   OF   THE   JAWS 


,+^r.  Ao.  7 


Fig.  175. — Adamantine  epithelioma  and  dentigerous  cyst.  Woman  aged 
thirty-seven  years.  Duration  of  growth,  twenty  years.  Removal.  Well 
after  five  years  (Bloodgood). 


THE    ODONTOMATA  187 

tumor  the  white,  finely  granular  tumor  tissue  and  multiple 
small  and  large  cysts  are  discovered. 

Carcinoma  usually  appears  connected  with  the  upper 
jaw,  and  in  later  life  than  the  adamantine  tumor.  Car- 
cinoma ulcerates  rather  early  if  it  is  starting  in  the  mouth. 
The  ulceration  of  the  adamantine  tumor  is  much  later,  and 
is  almost  always  associated  with  an  infection. 


Fig.     176. — Dentigerous    cyst.     Adamantine    epithelial    tumor.     Removed. 
Recovered  (W.  B.  Rogers). 

A  sarcoma  may  be  difficult  to  distinguish  from  a  solid 
adamantine  tumor.  If  all  the  teeth  are  present;  if  the 
tumor  is  of  the  upper  jaw  or  near  the  angle  of  the  lower 
jaw,  it  may  be  a  sarcoma. 

Gross  Pathology. — A  section  of  the  tumor  finds  a 
thin,  bony  wall  inclosing  the  tumor  proper,  which  is  usually 
partly  solid  and  partly  cystic.  The  cysts  are  filled  with 
clear,  yellowish  or  reddish,  slightly  viscid  fluid,  often  con- 


188 


TUMORS    OF    THE    JAWS 


f\ 

r  1 


Fig.  177. — Adamantine  epithelioma  and  dentigerous  cyst.  Man  fifty- 
four  years  of  age.  Duration  of  tumor,  twenty  years.  Operation  advised 
and  refused  (Halsted  and  Bloodgood). 


THE    ODONTOMATA 


189 


taining  cholesterin  crystals.     Bony  and  fibrous  trabeculse 
are  seen   to  separate  the  various  portions  of  the  tumor. 


Fig.  178. — Dentigerous  cyst.  Adamantine  epithelioma.  Man  aged 
forty-two  years.  Duration,  eight  years.  Fistula  into  the  mouth  and  ex- 
ternally. Operation.  Recovery  (Halsted  and  Bloodgood). 


Fig.  179. — Dentigerous  cyst.  Adamantine  epithelioma.  Man  aged 
forty-two  years.  Duration,  eight  years.  Fistula  into  the  mouth  and  ex- 
ternally. Operation.  Recovery  (Halsted  and  Bloodgood). 

The  cystic  parts  of  the  tumor  appear  similar  to  the  benign 
dentigerous  cyst. 


190 


TUMORS    OF    THE    JAWS 


The  solid  portions  have  a  characteristic  appearance. 
The  cut  surface  of  the  tumor  is  white  in  color,  and  of  a 
finely  granular  consistence. 

.1        * 

•¥.^»J^^ 
fci  - ' 


Fig.  180. — Adamantine  epithelioma,  showing  part  of  an  alveolus:  a, 
External  layer  of  cubic  and  cylindric  cells,  which  is  in  places  invaginated 
and,  therefore,  appears  to  be  within  the  alveolus;  b,  layer  of  cells  corresponding 
to  stratum  intermedium  (see  Fig.  159);  c,  tissue  formed  by  anastomosing 
stellate  cells,  corresponding  to  stratum  mucosum;  d,  invaginated  stroma;  e, 
blood-vessels  in  invaginated  stroma  (Steensland,  in  Journal  of  Experimental 
Medicine). 

Definite  alveoli  can  be  made  out,  and  the  granular 
material  may  be  scraped  away  with  the  knife. 

In  gross,  the  solid  portion  of  the  tumor  has  the  appear- 
ance of  a  squamous-cell  carcinoma. 


THE    ODONTOMATA  191 

Microscopic  Pathology. — The  appearances  in  more 
detail  are  as  follows  (I  have  followed  closely  Steensland's 
study  of  these  cases) : 

The  tumor  itself  consists  of  a  connective-tissue  stroma, 
in  which  there  are  alveoli  formed  by  epithelial  cells. 

The  epithelial  elements  represent  the  enamel  organ, 
and  are  largely  in  the  stage  corresponding  to  the  greatest 
development  of  the  stratum  mucosum  (Fig.  180).  One  or  two 
areas,  somewhat  removed  from  the  periphery,  represent  the 
stage  immediately  preceding  the  development  of  the  stratum 
intermedium  (see  Fig.  159)  and  the  stratum  mucosum  (Fig. 
181,  c).  No  definite  karyokinetic  figures  are  seen  here, 
but  some  nuclei  stain  more  deeply  than  others,  and  have  a 
slightly  ragged  surface.  This  is  represented  at  d,  Fig.  181, 
where,  apparently,  the  stratum  intermedium  is  beginning  to 
develop.  Intercellular  bridges,  perhaps  corresponding  to 
those  of  the  epithelium  of  the  mucous  membrane  of  the 
mouth,  are  seen.  The  appearance  here  suggests  carcinoma. 
In  many  places  the  stratum  mucosum  is  largely  replaced  by 
cysts  containing  a  finely  granular  material  staining  with 
eosin.  Anastomosis  of  the  alveoli  suggests  that  the  epithe- 
lial constituents  form  a  solid  framework  similar  to  that 
which  has  been  shown  to  exist  in  carcinoma  by  means  of 
reconstructed  serial  sections. 

In  the  large  alveoli  is  seen  an  external  layer  of  cells, 
which  in  some  places  are  cylindric;  in  other  places,  cubic 
(Fig.  180,  a).  The  layer  is  occasionally  invaginated,  and 
therefore  appears  in  the  section  to  be  situated  inside  of  the 
alveolus.  The  cylindric  cells  perhaps  correspond  to  the 
inner  epithelial  layer  of  the  enamel  organ;  the  cubic  cells, 
to  the  outer  epithelial  layer.  (See  Fig.  161  in  development 


192 


TUMORS    OF    THE    JAWS 


of  the  tooth.)  Often,  but  not  regularly,  within  the  external 
layer  are  one  or  more  layers  of  flattened  cells,  which  tend 
little  by  little  to  assume  the  stellate  form  and  correspond 
to  the  stratum  intermedium  (Fig.  180,  b). 


**-'•***$& 


'  I*  ^ 

^^       flMMU* 


X 


**       ^ 


Fig.  181. — Epithelioma  adamantinum :  a,  Stroma;  b,  b,  blood-vessels  in 
stroma;  c,  cells  representing  that  stage  which  precedes  the  formation  of  the 
stratum  intermedium  and  stratum  mucosum;  d,  cells  representing  the  early 
development  of  the  stratum  intermedium.  Nuclei  are  deeply  stained  and  have 
a  ragged  surface,  suggesting  karyokinesis  (Steensland,  in  Journal  of  Experi- 
mental Medicine). 


Occupying  most  of  the  interior  of  the  solid  alveoli  is 
the  most  characteristic  feature  of  the  tumor,  the  stratum 
mucosum,  or  enamel  pulp,  consisting  of  anastomosing 
stellate  cells  (Fig.  180,  c).  When  seen  under  a  lower 


THE    ODONTOMATA  193  v 

power,  it  might  be  mistaken  for  mucoid  tissue,  and,  espe- 
cially when  present  in  large  areas,  might  lead  to  a  diagnosis 
of  myxoma. 

There  are  imaginations  of  the  external  layer  of  cells 
which,  with  the  adjacent  stroma,  simulate  the  "Anlagen" 
of  teeth  in  their  early  stages  (Fig.  180,  a).  This  gives  to 
the  alveoli  the  appearance  of  gland  tubules  in  a  stroma  of 
mucoid  tissue  (Fig.  180),  especially  in  places  where  the 
invaginated  stroma  has  largely  lost  its  fibrillar  character 
and  appears  homogeneous  (Fig.  180,  d).  Evidences  of 
karyokinesis  are  seen  in  the  external  layer,  and  to  a  less 
extent  in  the  stratum  intermedium. 

Various  stages  in  the  development  of  cysts  are  well  seen. 
They  are  due  evidently  to  a  hyaline  and  granular  degener- 
ation of  the  stellate  cells,  and  to  an  accumulation  of  fluid 
between  these  cells.  The  formation  of  the  stratum  muco- 
sum  enamel  pulp  is  apparently  associated  with  an  accumu- 
lation of  fluid  between  the  cells,  the  formation  of  long 
processes  of  the  cellular  protoplasm,  and  the  gradual  dis- 
appearance of  the  intercellular  bridges  (Fig.  180).  No 
evidence  of  enamel,  dentin,  or  cement  is  seen.  Chibret  has 
described  the  formation  both  of  enamel  and  of  cemento- 
dental  tissue  in  a  similar  tumor.  The  stroma  (Fig.  181,  a) 
consists  of  dense  connective  tissue  in  which  only  a  few 
blood-vessels  (Fig.  181,  b,  b)  are  apparent. 

Kruse's  Description. — Of  the  microscopic  appearance 
of  these  tumors  a  clear  description  is  that  given  by 
Kruse.  He  reports  three  cases  representing  different  stages 
in  the  development  of  the  enamel  organ.  In  the  individ- 
ual cases,  also,  different  stages  are  represented.  In  the 
first  case  the  epithelial  constituents  consist  of  dendritically 

13 


194  TUMORS   OF   THE   JAWS 

branching  twigs,  composed  of  epithelial  cells,  and  forming 
solid  masses,  situated  in  a  poorly  vascularized  stroma. 

The  form  and  arrangement  of  the  cells  are  similar  to 
the  form  and  arrangement  of  the  cells  of  the  dental  ridge  in 
an  early  stage  of  development.  The  tumor,  therefore,  cor- 
responds in  its  structure  to  an  early  stage  of  the  "anlage" 
of  the  tooth. 

Kruse's  second  case  has  in  part  the  same  structure  as 
the  first,  but  there  is  more  tendency  toward  the  formation 
of  a  peripheral  layer  of  cylindric  cells.  In  some  places 
small  cysts  are  present,  and  there  is  one  macroscopic  cyst, 
2  cm.  in  diameter.  Comparison  with  a  somewhat  later  stage 
of  the  dental  "anlage,"  where  outer  and  inner  enamel 
epithelium,  stratum  intermedium,  and  stratum  mucosum  are 
present,  show,  according  to  the  description,  that  the  epi- 
thelial twigs  of  the  tumor  are  in  all  details  like  the  dental 
"  Anlage,"  and  that  the  relation  of  the  cells  to  each  other 
is  the  same. 

The  third  tumor  is  conspicuously  cystic.  Some  cysts  are 
microscopic  in  size,  while  the  largest  is  the  size  of  a  hen's  egg. 
But  the  solid  parts  are  microscopically  like  the  first  two 
tumors,  presenting  solid  twigs  of  polygonal  epithelial  cells, 
some  with  a  peripheral  layer  of  cylindric  cells,  some  with 
beginning  cyst-formation.  The  tumor  consists  largely  of 
well-developed  cysts.  The  size  and  the  structure  of  the 
cysts  vary,  but  in  general  a  definite  size  corresponds  to  a 
definite  arrangement  of  the  cells.  In  the  smaller  cysts  the 
wall  is  lined  with  low  cylindric  epithelium,  while  the  lumen 
contains  a  granular  hyaline  material.  The  larger  cysts 
are  lined  by  a  more  or  less  cubic  epithelium  and  three  or 
four  layers  of  squamous  cells. 


THE    ODONTOMATA  195 

There  is  then,  according  to  Kruse,  a  continuous  series 
representing  varying  degrees  of  differentiation,  each  of 
which  has  certain  individual  characters  and,  in  addition, 
presents  transitional  stages  to  the  others. 

Chibret's  work  is  especially  valuable.  He  describes 
a  case  in  which  there  is  a  pronounced  tendency  toward 
the  formation  of  the  various  tissues  of  the  teeth.  The 
case  presents  all  the  stages  in  the  formation  of  the  tooth  up 
to  the  development  of  enamel  and  of  cementodental  tissue. 
These  substances  are  found  at  the  borders  of  the  most 
highly  differentiated  alveoli.  The  cementodental  tissue 
resembles  cement,  since  it  contains  large  osteoblasts  and 
dentin,  and  since  branching  canaliculi  are  present  and  vessels 
are  wanting.  In  very  few  of  the  cases  described  in  the 
literature  does  there  appear  to  have  been  represented  the 
epithelial  sheath  of  Hertwig.  Perhaps  this  explains  the 
absence  of  roots  and  of  characteristic  cement  and  dentin. 

A  remarkable  specimen  is  described  by  Hildebrand. 
He  observed,  in  the  case  of  a  boy  nine  years  old,  an  exces- 
sive development  of  masses  of  teeth  in  the  interior  of  the 
upper  and  lower  jaw  bones  on  both  sides.  Not  only  con- 
glomerations of  teeth,  but  also  more  or  less  completely 
isolated  teeth,  were  present.  The  eruption  of  the  teeth 
appeared  to  have  been  entirely  irregular.  Perhaps  the 
entire  epithelial  "anlage"  of  the  teeth  had  assumed  an 
abnormal  function. 

Treatment  of  the  Adamantine  Epithelioma. — The 
operative  treatment  will  be  either  partial  or  complete. 
If  the  tumor  has  not  destroyed  the  whole  thickness  of  the 
bone  on  both  sides,  it  may  be  possible  to  remove  all  the 
new-growth  and  to  leave  a  bony  wall  to  support  the  jaw 


196  TUMORS    OF    THE    JAWS 

and  to  preserve  the  contour  of  the  face.  If,  on  the  con- 
trary, the  whole  thickness  of  the  jaw  is  destroyed  or  the 
bone  is  so  thinned  as  to  appear  an  inefficient  support  if 
left,  then  it  will  be  wise  to  resect  the  jaw  bone,  including 
all  of  the  growth. 

It  is  of  the  very  greatest  importance  to  decide,  upon 
incising  the  tumor,  whether  or  not  the  growth  is  probably 
benign  through  its  whole  extent.  If  there  is  little  or  no 
doubt  of  its  benignancy,  then  the  partial  operation  may  be 
done. 

Many  of  the  adamantine  tumors  hitherto  have  been 
treated  by  a  too  radical  procedure.  Recent  surgery  has 
demonstrated  conclusively  that  the  partial  operation  is  safe. 
The  complete  resection  under  these  conditions  is  unneces- 
sarily mutilating. 

There  is  usually  no  glandular  involvement  in  these 
cases.  Dissection  of  the  cervical  lymph-nodes  is  not  called 
for.  However,  if  a  complete  resection  is  done,  it  will  be 
wise  to  remove  the  lymphatic  glands  in  close  proximity, 
i.  e.,  those  of  the  submaxillary  and  submental  regions. 

There  are  no  cases  recorded  in  which  recurrences  have 
occurred  after  a  thorough  operation.  If  a  bit  of  the  cyst- 
wall  is  inadvertently  left  in  situ,  as  was  done  in  one  of  my 
own  cases,  a  new  cyst  may  form  at  the  old  operation  site 
and  necessitate  a  second  operation. 

The  prognosis  in  these  cases  of  adamantine  epithelioma 
is  good,  i.  e.,  there  is  no  local  recurrence  following  complete 
removal.  The  adamantine  tumor  is  not  dangerous  to  life. 

SELECTED  BIBLIOGRAPHY  OF  ODONTOMA 

Steensland:  Jour.  Exp.  Med.,  1904. 

Hildebrand:   Deut.  Zeit.  f.  Chir.,  1890-91,  vol.  xxxi,  p.  282;    1893,  vol.  xxxv. 


THE    ODONTOMATA  197 

Kruse:   Virchovv's  Arch.,  1891,  vol.  cxxiv,  p.  137. 

Chibret:  Arch,  de  med.  exper.,  1894,  vol.  vi,  p.  278. 

Becker:  Arch.  f.  klin.  Chir.,  1894,  vol.  xlvii,  p.  52. 

Malassez:  Arch,  des  physiol.  norm,  et  path.,  1885,  vol.  v,  p.  129;  ibid.,  1885, 

vol.  v,  p.  309. 

Krause:   Virchow's  Arch.,  1891,  vol.  cxxiv,  p.  137. 
Pincus,  Walther:   Arch.  f.  klin.  Chir.,  vol.  Ixxii,  pp.  995-1021. 
Oliver,  J.  C.:    Trans.  Amer.  Surg.  Assoc.,  Philadelphia,  1902,  vol.  xx,  pp. 

383-395. 

Barrie,  Geo. :   Annals  of  Surg.,  September,  1905. 
Sirantoine,  Leon  Alfred:   Etude  Critique  sur  la  Pathogenic  des  Kystes  Para- 

dentaires  Uniloculaires,  I.  D.  Nancy,  1903. 

Borst,  Max:   Die  Lehre  von  den  Geschwiilsten,  1902,  vol.  ii,  p.  605. 
Kuhlo,  Friedrich:    I.  D.  Leipzig,  1903  (Trendelenburg's  clinic). 
Martens:  Charite  Ann.,  Berlin,  1903,  vol.  xxvii,  pp.  288-295. 
Bloodgood:    Buck's  American  Practice  of  Surgery. 


CYSTS  OF  THE  JAW 

There  are  two  kinds  of  cysts  of  the  jaw,  the  follicular  or 
dentigerous,  and  the  periosteal  or  root-cysts. 

The  follicular  or  dentigerous  cysts  start  previous  to  com- 
pleted dentition.  They  are  unassociated  with  injury  or 
disease.  The  periosteal  or  root-cysts  may  arise  at  any 
time,  and  are  associated  with  normally  placed  adult  teeth, 
often  carious. 

DENTIGEROUS  CYST  (FOLLICULAR  ODONTOMA) 

This  is  not  an  uncommon  form  of  benign  odontoma.  It 
occurs  in  the  lower  jaw  a  little  more  frequently  than  in  the 
upper  jaw.  In  the  lower  jaw  it  is  often  seen  as  a  small 
swelling  under  the  gum,  the  size  of  an  olive,  upon  the  outer 
side  of  the  alveolus.  Upon  the  tongue  side  of  the  jaw  the 
cyst  of  this  size  does  not  encroach.  Palpated  upon  the 
outer  side,  the  cyst-wall  will  feel  thin  and  parchment-like, 
and  may  cause  a  crackling  sensation  upon  deep  pressure 
as  the  thin  covering  is  indented  by  the  finger. 


198  TUMORS    OF    THE    JAWS 

The  cyst  appears  in  the  jaws  near  to  the  row  of  teeth. 
A  tooth  may  be  congenitally  misplaced.  A  cyst  develop- 
ing in  the  paradental  rest  of  a  misplaced  tooth  is  spoken 
of  as  a  heterotopic  cyst.  Thus,  both  Dupuytren  and 
Paget  record  cases  occurring  in  the  hard  palate. 

The  cyst  rarely  appears  during  the  first  dentition.     It 


Fig.  182. — Dentigerous  cyst  of  upper  jaw.  Colored  girl,  aged  nineteen; 
swelling,  thirteen  years;  parchment  crepitation;  teeth  normal.  Complete 
excision  of  upper  jaw  on  diagnosis  of  sarcoma.  Death  from  pulmonary  abscess 
(from  original,  loaned  by  Joseph  C.  Bloodgood). 

appears  in  adolescence  and  young  adult  life,  i.  e.,  during  or 
after  the  second  dentition,  rarely  after  forty. 

There  is  sometimes  a  tooth  missing  from  the  jaw,  un- 
erupted,  after  a  dentigerous  cyst  has  developed.  When  the 
cyst  develops  after  the  second  dentition,  it  usually  arises 


THE    ODONTOMATA 


199 


from  the  wisdom-teeth.  Magitot  records  nine  cases  be- 
tween the  years  of  twenty  and  thirty,  all  of  which  started 
from  the  "anlage"  of  a  wisdom-tooth. 

The  growth  of  the  cyst  is  slow,  causing,  if  in  the  center 
of  the  bone,  a  gradual  expansion  of  the  bony  walls  of  the 
jaw. 

Unlike  other  cysts  associated  with  new-growths,  the 
development  of  the  cyst  advances  along  with  a  new-growth 


Fig.  183. — Benign  dentigerous  cyst  of  the  upper  jaw.     Girl,   nineteen  years 
old.     Duration,  thirteen  years  (Bloodgood). 

of  bone  in  its  wall,  so  that  the  bony  wall  is  not  a  mere  ex- 
pansion of  a  previously  existing  bony  capsule,  with  subse- 
quent pressure  atrophy  and  thinning  of  the  wall,  but  the  shell 
of  bone  is  formed  over  the  advancing  and  expanding  tumor. 


200 


TUMORS    OF    THE    JAWS 


Fig.   184. — Dentigerous  cyst  of  the  lower  jaw.     Woman,  aged  twenty-one. 
Good  recovery  (Army  Medical  Museum,  No.  1258.     See  Fig.  185). 


Fig.  185. — Same  case  as  Fig.  184.     Dentigerous  cyst  of  the  left  lower  jaw 
in  a  woman  aged  twenty-one. 


THE    ODONTOMATA  201 

When  seated  in  the  upper  jaw,  these  cysts  may  reach 


* 


Fig.  186. — Benign  dentigerous  cyst  of  the  lower  jaw  (J.  C.  Warren  collection). 


Fig.  187. — Lower  jaw.  Multilocular  dentigerous  cyst,  benign,  in  a 
woman  twenty-nine  years  old.  Duration  of  the  tumor,  a  little  over  a  year 
(Warren  Museum.  Xo.  4324). 

enormous  size.     There  is  little  pain  ordinarily  associated 
with   their   growth.     If   the   cyst-wall   should   include   the 


202 


TUMORS    OF    THE    JAWS 


inferior  dental  nerve,  pain  might  be  caused  in  the  distribu-, 
tion  of  this  nerve. 

The    mucous    membrane    covering    this    tumor    is    not 
found  ulcerated.     Fistula  is  uncommon. 

The  molar  or  canine  teeth  are  the  ones  most  often  miss- 
ing in  connection  with  the  development  of  these  cysts,  so 


Fig.  188. — Same  as  Fig.  187.  Benign  dentigerous  cyst  of  lower  jaw  cut 
in  section.  Note  many  cysts.  Nothing  malignant  in  growth  (Warren 
Museum,  No.  4324). 

that  the  common  seat  is  unilateral.  Barrie's  case  was 
exceptionally  placed  at  the  symphysis  of  the  lower  jaw. 
There  is  really  no  reason  why  these  cysts  should  not  de- 
velop anywhere  in  the  body  of  the  jaw. 

In  the  case  of  Rogers  (see  Figs.  201,  202)  the  mouth 
was  occupied  almost  wholly  by  the  bulging  tumor,  so  that 


THE    ODONTOMATA  203 

the  tongue  was  depressed  backward  and  its  tip  could  not 
be  placed  within  a  long  distance  of  the  lips. 

The  lower  teeth  are  so  displaced  and  loosened  that  they 
cannot  be  opposed  to  those  of  the  upper  jaw.  Food  requir- 
ing mastication  cannot  be  taken.  Liquid  and  soft  solid 
nourishment  has  to  be  taken.  Articulation  is  most  diffi- 
cult. Such  is  the  picture  of  a  benign  dentigerous  cyst 
which  has  progressed  far.  Examination  of  the  mucous 


Fig.  189. — Dentigerous  cyst  of  the  lower  jaw  from  a  woman  aged  sixteen. 
Recovery.  Tooth  seen  in  the  cavity  of  the  cyst  (Army  Medical  Museum, 
No.  7439). 

membranes  will  find  in  such  cases  no  ulceration,  and  very 
likely  no  cervical  lymphatics  will  be  enlarged. 

Etiology. —  Dentigerous  cysts  arise  from  the  over- 
growth of  some  part  of  the  follicle  of  a  non-erupted  tooth. 
According  to  the  stage  of  the  development  of  the  tooth  in 
connection  with  which  the  cyst  forms,  there  will  be  found,  at 
operation  or  upon  examination  after  operation,  the  whole 
or  part  of  a  tooth-like  object,  in  appearance  sometimes 


204  TUMORS   OF   THE   JAWS 

resembling  the  crown  or  even  the  whole  tooth.  The  crown 
of  the  tooth  is  usually  looking  toward  the  interior  of  the  cyst, 
and  the  root  looks  outward.  The  cyst  lies  over  the  crown 
of  the  tooth,  which  lies  at  the  base  or  bottom  of  the  cyst. 
(See  Fig.  189.) 

The    tooth-like    bodies    seen   in    these    follicular    cysts 
consist  usually  of  the  crowns  of  teeth;   the  root  is  the  least 


Fig.  190. — Dentigerous  cyst  of  each  half  of  the  lower  jaw.     In  one  specimen  a 
rudimentary  tooth  may  be  seen  (Army  Medical  Museum,  No.  5285). 

well-developed  part.  There  may  be  a  number  of  these 
tooth-like  bodies  in  the  cyst.  There  may  be  as  many  as 
25  to  100  or  more  pieces  of  partly  developed  teeth.  (See 
Figs.  213,  214.) 

Case  of  Cystic  Odontoma. — A.  C.,  thirty-two  years 
old.  General  health  has  always  been  good.  Both  the  upper 
and  lower  wisdom-teeth  have  been  removed.  The  present 


THE    ODONTOMATA 


205 


difficulty  began  four  summers  ago,  with  pain  in  the  region 
of  the  right  lower  jaw.  The  pain  was  accompanied  by  a 
swelling  in  this  region. 

Examination  finds  a  tumor  occupying  the  region  of  the 
right  lower  jaw,  involving  the  whole  thickness  of  the  angle 
of  the  jaw,  and  about  the  size  of  a  small  flat  orange. 


Fig.  191.— Excision  of  right  half  of  Fig.   192.— Drawing  of  tumor 

lower  jaw  for  a  dentigerous  cyst.    Note  in  case  Fig.  191.     Note  relation  of 

line  of  incision  and  patient's  side  face  tumor  to  jaw. 
after  operation  (author's  case). 

Operation:  One-half  of  the  lower  jaw  was  excised,  the 
bone  being  removed  from  the  temporal  maxillary  joint  to 
just  behind  the  right  canine  tooth. 

Pathologic  report:  Warren  Museum,  Specimen  No. 
9263.  The  specimen  consists  of  the  ramus  and  about  5  cm. 
of  the  body  of  the  right  side  of  the  lower  jaw.  The  greater 
part  of  this  is  occupied  by  a  new-growth  projecting  chiefly 
on  the  inner  surface,  replacing  the  bone,  leaving  only  a 
thin  shell  externally.  The  tumor  is  partly  cystic  and 


206 


TUMORS    OF    THE    JAWS 


partly  solid;  the  greater  part  is  a  cyst  about  4  cm.  in  diam- 
eter, lying  mostly  in  the  ramus,  and  extending  from  the 
tip  of  the  coronoid  process  toward  the  angle.  Several  very 
much  smaller  cysts  lie  about  it,  and  in  the  body  is  the  more 
solid  part  of  the  tumor,  which  has  a  finely  spongy  section 
surface.  Lying  directly  upon  this  is  a  molar  tooth,  appar- 
ently pressed  out  of  its  socket  by  the  invasion  of  the  growth, 
which  is  here  sharply  defined  from  the  bone. 


Fig.  193. — Same  specimen  as  Fig.  192.     Note  relation  of  cyst  to  jaw. 

Microscopic  examination  showed  a  fibrous  tissue  ground 
and  framework,  in  place  of  which  were  solid  masses  of  long 
narrow  cells,  in  general  aspect  recalling  those  of  a  tooth 
follicle.  These  permeated  the  tissue  in  different  directions 
as  irregularly  branching  columns.  Often  the  center  of  these 
columns  was  occupied  by  a  series  of  anastomosing  star- 
shaped  cells  with  fine  connecting  prolongations,  recalling 
a  myxomatous  tissue.  In  others  there  was  a  cavity  in  the 
center  filled  with  a  clear  fluid,  and  where  numbers  of  these 


THE    ODONTOMATA  207 

small  cysts  were  contiguous,  the  connective  tissue  between 
them  was  reduced  to  a  thin  partition,  and  the  whole  had 
a  finely  honey-combed  appearance.  From  these  to  the 
larger  (macroscopic)  cysts  all  stages  were  to  be  found. 

The  growth  can  be  classed  as  a  cystic  follicular  odontoma. 

Subsequent  History. — General  health  has  been  excellent. 
Three  years  after  the  operation  a  swelling  appeared  at  the 
middle  of  the  old  incision.  This  swelling  was  accompanied 
by  a  little  pain.  Swelling  became  the  size  of  an  English 
walnut,  and  then  a  second  operation  was  done,  about  three 
years  after  the  first  operation.  The  tumor  was  removed, 
and  was  found  to  have  been  a  small  cyst,  starting  probably 
from  a  bit  of  the  membrane  of  the  original  cyst. 

Present  condition — three  years  after  the  last  operation, 
six  years  after  the  first  operation:  General  health  is  perfect, 
and  there  has  been  no  local  recurrence  of  the  growth. 


The  tooth  will  occupy  different  positions  in  the  cyst. 
It  may  be  concealed  in  the  wall  of  the  cyst,  and  be  covered 
by  living  membrane ;  it  may  lie  free  in  the  cavity;  it  may  be 
upright  in  a  natural  position,  or  lie  crooked  and  in  an  unus- 
ual position.  The  tooth  may  not  be  seen  at  the  operation; 
indeed,  if  the  cyst  has  begun  to  form  at  an  early  period 
in  the  development  of  the  tooth-follicle,  it  is  perfectly 
conceivable  that  no  tooth  will  be  grown  at  all  in  that  partic- 
ular cyst.  Just  because  a  tooth  is  absent  from  a  cyst  does 
not  mean  that  the  tumor  is  not  a  true  dentigerous  cyst. 
Malassez's  theory  of  the  origin  of  dentigerous  cysts  is  the 
most  reasonable  of  all  theories. 

Malassez  explains  the  origin  of  the  dentigerous  cyst  as  he 
explains  the  origin  of  other  odontomata,  viz.,  by  the  develop- 


208 


TUMORS    OF    THE    JAWS 


merit  of  the  epithelial  paradental  rests.  Barrie  has  reported 
a  case  of  dentigerous  cyst  of  the  lower  jaw.  This  case  is 
one  of  very  considerable  value.  The  histologic  examina- 
tion (Bloodgood)  discovers  that  the  wall  of  the  cyst  is 
lined  with  distinct  adamantine  epithelium.  Consequently, 
this  dentigerous  cyst  has  the  same  origin  as  the  adamantine 


Fig.  194. — Girl,  twelve  years  old. 
Dentigerous  cyst  of  right  lower  jaw, 
said  to  have  been  noticed  eight 
months  previously  (F.  W.  Dudley. 
Manila,  P.  I.). 


Fig.  195. — Girl,  twelve  years  old. 
Dentigerous  cyst  of  right  lower  jaw, 
said  to  have  been  noticed  eight 
months  previously  (F.  W.  Dudley, 
Manila,  P.  I.). 


epithelium,  viz.,  from  the  " epithelial  paradental  rests." 
This  case  of  Barrie's  establishes,  upon  a  pretty  firm  basis, 
the  etiology  of  the  dentigerous  cysts  according  to  Malassez's 
theory. 

This   observation   is   in   line   with   the   well-recognized 
fact  that  the  adamantine  epithelioma  and  the  dentigerous 


THE    ODONTOMATA  209 

cyst  are  often  found  together.  A  more  careful  microscopic 
examination  of  the  fresh  dentigerous  cysts  operated  upon 
will  doubtless  confirm  the  very  valuable  observation  of 
Bloodgood  in  the  case  of  Barrie. 

Whether  the  cyst  forms  because  of  a  disturbance  in  the 
development  of  the  normally  placed  tooth-follicle  (Broca), 


Fig.  196. — Benign   dentigerous   cyst   of  lower   jaw.      Woman,  thirty-seven 
years  old  (F.  W.  Dudley,  Manila,  P.  I.). 

or  whether  it  is  due  to  a  misplaced  paradental  rest  develop- 
ing, it  is  difficult  to  decide.     Both  views  are  possible. 


W.  F.  H.  Massachusetts  General  Hospital  series,  No. 
142,209.  A  man,  twenty-two  years  old,  who  first  noticed  a 
swelling  of  his  chin  three  months  previously.  He  had  no 
pain  or  tenderness  in  connection  with  this  swelling.  The 
swelling  appeared  within  the  mouth,  the  outer  side  of  the 
jaw,  and  to  the  left  of  the  median  line.  Palpation  of  the 
14 


210 


TUMORS    OF    THE    JAWS 


swelling  within  the  lip  disclosed  a  soft  area.  There  was  a 
missing  canine  tooth  upon  this  same  side,  and  a  slight 
puriform  discharge  from  the  tooth-socket.  The  tumor  was 
incised  through  the  mucous  membrane  of  the  mouth,  the 
cavity  cureted,  and  a  counteropening  made  and  the  cavity 


Fig.  197. — Case  of  dentigerous 
cyst.  Note  the  swelling  of  the  cheek 
over  the  tumor. 


Fig.  198. — Same  case  as  Fig. 
197.  Xote  the  tumor  of  the  alve- 
olar border  of  the  jaw,  its  size,  its 
situation,  its  position  on  the  outer 
side  of  the  jaw. 


packed  with  gauze.  The  cavity  healed  in  about  five 
months.  Practically  well  at  the  end  of  this  time.  (See  Figs. 
197  and  198.) 


Pathology. — The  cyst  is  often  single.  (See  Figs.  183, 
190.)  Occasionally  the  tumor  is  composed  of  multiple 
cysts.  (See  Figs.  187,  188.) 


THE    ODONTOMATA 


211 


The  walls  of  these  cysts  are  more  or  less  irregular,  and  on 
the  inner  surface  are  lined  by  a  layer  of  fibrous,  tissue-like 
membrane,  sometimes  an  epithelial  layer,  often  only  by 
granulation  tissue.  Barrie's  case  has  already  been  referred 
to,  which  was  lined  by  adamantine  epithelium. 

The  contents  of  these  cysts,  besides  a  fully  formed  or 
partially  developed  tooth,  consist  of  a  sanguinolent  material 


Fig.  199. — X-ray  of  same  case  as  Fig.  198.     Note  the  tumor  and  absence  of  a 
tooth  in  that  location. 

or  a  clear  or  bloody  or  gelatinous  fluid,  which  may  contain 
cholesterin  crystals.  Calcification  may  take  place  in  the 
wall  of  a  dentigerous  cyst.  The  contents  may  resemble 
sebaceous  material,  which  will  be  found  to  be  made  up  of 
fatty  degenerated  epithelial  cells  and  cholesterin  crystals. 
This  type  of  cyst  does  not  become  much  larger  than  a  butter- 
nut. Its  inner  wall  is  lined  with  cuboid  and  stratified 


212 


TUMORS    OF    THE    JAWS 


epithelium.  All  the  teeth  are  usually  found  present  in  the 
jaw.  (See  Fig.  197.)  These  dermoid-like  cysts  probably 
arise  from  the  paradental  rests. 

Follicular  cysts  then  may  have  within  them,  or  lying  in 
the  wall  of  the  cyst,  an  almost  perfectly  developed  tooth, 


Fig.  200. — Same  case  as  Figs.  198  and  199,  showing  the  wall  of  the  cyst 
lining  the  cavity.  Note  the  epithelial  lining,  the  fibrous  tissue,  and  the  spaces 
filled  with  cholesterin  crystals  (photograph  by  Brown,  Massachusetts  General 
Hospital  laboratory). 

a  partially  developed  tooth,  a  very  rudimentary  tooth, 
a  piece  of  bone-like  or  dentin-like  material,  or  nothing  to 
suggest  teeth  at  all. 

The  toothless  follicular  cyst  of  the  lower  jaw  Mikulicz 
has  called  a  dermoid  of  the  jaw. 

As  in  Barrie's  case,  the  surface  of  the  lining  membrane 


Fig.  201. — Multilocular  dentig- 
erous  cyst  (See  Fig.  202.)  (W. 
B.  Rogers). 

r 


Fig.  202. — Multilocular  dentigerous 
cyst  of  three  years'  duration  (W.  B. 
Rogers). 


Fig.  203. — Appearance  after 
removal  of  the  multilocular  dentig- 
erous cyst  seen  in  Fig.  202  (W.  B. 
Rogers). 


Fig.  204. — Benign  dentigerous 
cyst  of  lower  jaw.  Woman,  thirty- 
seven  years  old  (F.  W.  Dudley, 
Manila,  P.  I.). 


213 


214 


TUMORS    OF    THE    JAWS 


may  not  be  perfectly  smooth,  but  elevated  in  spots,  these 
elevations  projecting  into  the  interior  in  a  pedunculated 
fashion.  This  capsule  may  contain  cells  which  resemble  and 
suggest  the  stellate  cells  of  the  stellate  reticulum. 

The  multilocular  cysts  which  occur  occasionally  in  the 
lower  jaw  and  attain  considerable  size  in  young  adults  are 
probably  multilocular  dentigerous  cysts.  The  most  plausi- 
ble theory  for  their  origin  is  that  of  Malassez — from  the 


Fig.  205. 


Fist.  200 


Figs.   205  and  206. — Benign  dentigerous   cyst  following  blow  upon  cheek. 
Girl  aged  nineteen  years.  Duration,  thirteen  years  (Halsted  and  Bloodgood). 

debris  epitheliaux  paradentaires.  Clinically  and  patho- 
logically, they  resemble  the  dentigerous  cyst.  In  the 
absence  of  sarcomatous  or  carcinomatous  tissue  in  their 
walls  they  should  receive  treatment  similar  to  that  given 
the  dentigerous  cyst.  If  the  bone  of  the  jaw  is  completely 
destroyed  and  no  possible  bony  bridge  can  be  secured  for 
support,  even  if  no  sign  of  malignancy  is  present,  the  tumor 
should  be  resected. 


THE    ODONTOMATA  215 

A  Case  of  Papillary  Cystadenoma  Arising  From 
the  Tooth-follicle.— W.  H.  W.  Thirty-six  years  old. 
Massachusetts  General  Hospital  series.  September,  1904. 

Five  or  six  years  ago  he  had  an  ulceration  of  a  right 
molar  tooth.  Following  this  there  appeared  a  hard  swell- 
ing at  the  site  of  the  present  tumor.  The  growth  of  the 
swelling  was  slow,  but  continuous.  It  had  grown  more 
rapidly  during  the  past  year.  It  was  painless.  It  had  been 


Fig.  207. — Benign  dentigerous  cyst.     Girl  aged  nineteen  years.     Duration, 
thirteen  years.     Same  case  as  Figs.  205  and  206  (Halsted  and  Bloodgood). 


incised  for  pus,  but  none  was  ever  found.  The  first  and 
second  teeth  were  normal  in  number  and  position.  The 
teeth  in  the  region  of  the  tumor  were  extracted  two  years 
ago.  There  are  only  two  incisors  left  in  the  right  mandible, 
and  these  are  deformed. 

The  x-ray  shows  a  cystic  tumor.  There  is  a  fluctuating 
area  over  the  tumor  which  extends  from  the  symphysis  to 
the  angle  of  the  jaw.  (See  Figs.  208,  209.)  There  is  no 
ulceration.  The  swelling  is  chiefly  outward,  that  is,  away 
from  the  mouth  cavity. 


216 


TUMORS    OF    THE    JAWS 


Fig.  208. — Papillary  cystadenoma  Fig.  209. — Note  tumor  of  alveolar 
or  follicular  odontoma.  Tumor  of  border  corresponding  to  the  external 
right  lower  jaw.  tumor. 


Fig.  210. — Appearance  in  front   view     Fig.  211. — Appearance  in  lateral  view 
after  operation.  after  operation. 


THE    ODONTOMATA 


217 


Operation :  An  incision  was  made  from  the  angle  of  the 
mouth  diagonally  backward  and  downward.  There  was 
found  a  thin,  crackly  shell  of  a  multilocular  cyst,  the  size 
of  a  peach,  containing  a  clear,  glairy  fluid  of  an  amber  hue. 
The  bony  cyst-wall  was  absent  over  a  part  of  the  tumor,  and 


Fig.  212. — Follicular  odontoma:  a,  b,  Models  of  lower  jaw  indicating 
the  original  position  of  the  tumor;  c,  d,  models  of  upper  jaw,  exhibiting  the 
displacement  of  the  teeth  (Cousins).  (See  Fig.  215.) 

was  replaced  by  a  soft,  homogeneous  tissue,  strongly  sug- 
gestive of  malignancy.  A  preliminary  report  by  the  path- 
ologist was  made  of  malignancy,  and,  therefore,  one-half 
of  the  jaw  was  removed. 

At  present,  seven  years  after  the  operation,  there  is  an 
absence  of  all  trouble  with  the  jaw.  (See  Figs.  210,  211.) 


218 


TUMORS    OF    THE    JAWS 


Pathologic  report  (49-71),  September,  1904:  Fragments 
of  a  cystic  tumor  of  the  jaw,  composed  of  thin,  scale-like 
pieces  of  bone  partly  lined  with  a  thin,  mucous-like  mem- 
brane, and  partly  with  thick,  soft,  rather  papillary  tissue. 
Microscopic  examination  of  the  more  solid  portion  showed 
a  branching,  tubular,  gland-like  arrangement  of  the  epithe- 


Fig.  213. — Tooth-like  masses  removed  from  the  interior  of  afollicularodontoma 
of  the  jaw  (Warren  Museum  specimen). 

lial  cells,  the  basement  membrane  of  which  seemed  every- 
where intact.  Papillary  cystadenoma,  probably  from  a 
tooth-follicle. 

(Signed)     W.  F.  WHITNEY. 


Diagnosis. — The  dentigerous  cyst  usually  develops  in 
the  lower  jaw.     It  is  situated  near  the  angle  of  the  jaw,  in 


THE    ODONTOMATA 


219 


the  region  of  the  molar  teeth.  The  crackle  to  palpation 
suggests  a  cyst.  A  puncture  of  what  is  probably  a  cystic 
tumor,  if  the  puncture  is  made  within  the  mouth,  is  wise  for 
diagnosis.  An  absent  permanent  tooth  is  suggestive  that  a 
slowly  growing  tumor  in  a  young  adult  is  a  dentigerous  cyst. 


Fig.  214. — Tooth-like  masses  removed  from  a  follicular  odontoma  of  the  jaw 

(Warren  Museum). 

A  dentigerous  cyst  may  be  mistaken  for  a  solid  tumor, 
particularly  if  it  is  of  the  upper  jaw.  If  the  cyst  grows  in 
the  center  of  the  lower  jaw,  it  may  simulate  a  solid  growth. 

It  is  always  to  be  borne  in  mind  that  an  adamantine 
epithelioma  may  be  associated  with  the  simple  dentigerous 
cyst;  in  fact,  it  is  a  not  infrequent  accompaniment  of  this 
cyst.  A  sarcoma  may  develop  in  the  wall  of  the  cyst. 


220 


TUMORS    OF    THE    JAWS 


(See  Figs.  172  and  173.)     The  x-ray  will  prove  of  much 
assistance  in  diagnosis. 

Treatment. — Having  made,  by  exploratory  puncture 
and  by  discovering  a  tooth  or  tooth  remains,  a  diagnosis  of 
a  dentigerous  cyst,  the  treatment  consists  in  the  removal  of 
one  wall  of  the  cyst,  thorough  curetage  of  the  interior  of  the 
cyst,  and  the  packing  of  the  space  thus  made  with  iodoform 
gauze  (Partsch). 


Fig.  215. — Follicular  odontoma  (Cousins).  (See  Fig.  212.)     Many  tooth-like 
bodies  removed  from  tumor.     Appearance  of  patient  in  1896. 

If  the  situation  of  the  cyst  permits,  it  is  wise  to  so 
fashion  the  bone  about  the  cystic  cavity  that  a  minimum 
amount  of  deformity  will  result  after  healing  has  taken  place, 
and  at  the  same  time  the  maximum  strength  will  be  secured 
for  the  remaining  bony  jaw.  It  may  be  possible  to  secure 
a  flap  of  normal  mucous  membrane  to  cover  the  defect,  and 
then  healing  will  be  hastened.  Almost  all  operative  pro- 
cedures upon  these  cysts,  even  the  larger  ones,  can  be  con- 


THE    ODONTOMATA 


221 


ducted  through  the  mouth.     It  will  be  rarely  necessary  to 
divide  the  cheek. 


Fig.  216. — Appearance  of  patient  in  1899  (Cousins). 


Fig.  217. — Appearance  of  patient  in  1907  (Cousins). 

If,  because  of  the  location  of  the  tumor,  it  is  thought 
wise  to  approach  it  by  a  skin  incision  to  avoid  mouth  infec- 


222 


TUMORS    OF    THE    JAWS 


tiori,  just  under  the  body  of  the  jaw,  the  incision  should  be 
made  so  as  to  be  concealed;  then  the  mucous  membrane 
should  be  reflected  off  and  over  the  tumor  through  the  skin 
incision.  The  surgeon  should  consider  the  presence  or 
absence  of  an  infection  already  existing  within  the  cyst, 
for  if,  upon  carefully  approaching  the  cyst  from  the  outside, 
infection  is  already  present,  the  object  of  the  procedure 
would  be  defeated. 


Fig.  218. — A  follicular  cyst  of  the  lower  jaw  in  a  man  thirty-four  years  old. 
Duration  of  growth,  nine  years.  Bony  wall  partially  removed.  Necrosis 
of  bone  limited  in  extent.  A  bicuspid  tooth  displaced  at  bottom  of  cyst  re- 
moved; complete  recovery  (Heath). 

It  must  be  remembered  that  dentigerous  cysts  which 
have  existed  in  such  intimate  relation  to  the  mouth  cavity 
often  become  infected  from  the  mouth  through  minute 
communication  with  their  interiors  around  the  roots  of  the 
teeth.  Heath  has  suggested  the  pressing  of  the  two  walls 
of  the  cyst  firmly  together  in  order  to  preserve  as  much 
bony  support  as  possible. 

Albarran  always  does  a  complete  extirpation,  to  be 
absolutely  sure  of  no  recurrence.  This  is  unnecessary  in 
most  cases. 


THE    ODONTOMATA 


223 


COMPOUND  FOLLICULAR  AND  COMPOSITE  ODONTOMATA 
These  are  varieties  of  odontoma  originating  from  certain 
portions  of  the  tooth-follicle.  They  are  composed  of  vary- 
ing combinations  of  the  several  tissues  of  the  tooth-follicle. 
They  may  contain  fibrous  tissue,  cysts,  bits  of  enamel, 
dentin,  and  cement.  Often  queerly  shaped  masses  resem- 


Fig.  219. — An  .r-ray  of  a  follicular  cyst  in  the  lower  jaw  of  a  nine-year-old 
girl.     A  displaced  molar  tooth  seen  (Perthes). 

bling,  in  some  instances,  teeth  are  found  loosely  attached  or 
free  within  the  cyst-wall.  These  masses  may  be  very  nu- 
merous. (See  Figs.  213,  214.)  These  tumors  may  grow  to  be 
of  large  size. 

Dental  cysts  occur  usually  in  the  upper  jaw  in  connection 
with  the  permanent  teeth.  They  rarely  attain  large  size; 
usually  they  are  as  large  as  an  olive  before  treatment  is 


224 


TUMORS   OF   THE   JAWS 


sought.  Dental  cysts  are  associated  with  the  canine  or 
incisor  teeth  and  never  contain  rudimentary  teeth  or  tooth 
remains.  They  are  thus  distinguished  from  small  den- 
tigerous  cysts  in  that  the  latter  are  situated  in  the  lower 
jaw,  and  usually  in  connection  with  the  molar  teeth. 

Dental  cysts  give  rise  to  slight  swelling  of  the  lip  and 

cheek.  They  are  of  slow 
growth,  and  usually  painless 
unless  they  grow  to  great 
size.  (See  Fig.  220.) 

If  the  bony  wall  is  thin 
enough,  it  will  yield  to  pres- 
sure of  the  palpating  finger 
and  cause  a  crackling  sensa- 
tion. A  puncture  of  the 
swelling  will  settle  the  diag- 
nosis of  a  cyst.  Puncture 
yields  a  thin,  glairy  fluid, 
clear  and  rarely  bloody, 
occasionally  purulent. 

The    situation    of    these 
cysts  is  illustrated  in  Figs. 
224  and  225,  about  the  roots 
of  the  upper  j  aw.    Such  cysts, 
if  allowed  to  grow,  may  de- 
press the  roof  of  the  mouth  or  fill  the  antrum.    (See  Fig.  227.) 
If  the  permanent  teeth  are  normally  erupted  and  a  cyst 
is  present,  it  is  more  than  probable  that  it  is  a  simple  dental 
cyst  associated  with  the  root  of  a  tooth. 

The  walls  of  these  dental  cysts  are  usually  lined   by 
granulation  tissue,  occasionally  by  epithelial  cells. 


Fig.  220. — Dental  cyst.  Note 
the  partial  obliteration  of  the  right 
nasolabial  sulcus  over  the  tumor. 
Note  the  absence  of  teeth  from  the 
upper  jaw.  No  recurrence  after 
operation. 


THE    ODONTOMATA 


225 


These  cysts  should  be  completely  removed  if  recurrence 
is  to  be  avoided.  The  whole  wall  should  be  destroyed. 
It  is  usually  sufficient  to  remove  the  anterior  wall  of  the 
cyst  completely,  then,  exposing  the  interior  of  the  cyst, 
the  lining  (granulation  tissue — epithelial  tissue)  should  be 
thoroughly  removed  or  completely  destroyed  by  applica- 


Fig.  221. — Dental  cyst.  Section,  frontal,  showing  nasal  fossa  and  relation 
of  root-cyst  to  antrum  and  inferior  meatus.  a,  Tooth  in  bottom  of  cyst;  6, 
top  of  cyst  next  to  antrum. 

tion,  upon  small  swabs,  of  strong  carbolic  acid.  Recurrence 
has  occurred  when  less  thorough  methods  have  been  followed. 
The  cavity  remaining  after  this  destruction  of  the  cyst 
should  be  packed  with  some  antiseptic  gauze.  If  the 
situation  of  the  cyst  is  such,  it  may  be  possible  to  reflect 
the  mucous  membrane  from  off  the  cyst,  and  so  to  preserve 

15 


226  TUMORS   OF   THE   JAWS 

it  that,  after  the  cyst-wall  is  destroyed,  the  mucous  mem- 
brane may  be  laid  as  a  plastic  flap  over  the  cavity,  and 
thus  healing  be  hastened  and  facilitated. 

THE  ROOT-CYSTS 

These  are  the  most  frequent  forms  of  cysts.  Of  course, 
they  are  of  comparatively  little  general  surgical  importance. 
They  are  mentioned  here  so  that  the  subject  may  be  under- 
stood in  its  proper  relations. 


Fig.  222. — A  root-cyst  of  the  upper  jaw  in  connection  with  the  first  molar  tooth. 
Xote  the  very  rounded  surface  of  the  tumor  (Perthes). 

Partsch,  in  two  years,  saw  200  cases  of  root-cyst  and 
only  6  follicular  cysts. 

Root-cysts  are  almost  never  seen  in  connection  with 
the  milk-teeth.  Root-cysts  occur  in  the  upper  jaw  more 
frequently  than  in  the  lower  jaw. 

They  lie  in  connection   with  the   incisor  and   bicuspid 


THE    ODONTOMATA 


227 


teeth.  They  rest  in  a  smooth  bony  cavity  of  the  tooth 
alveolus.  The  wall  of  the  cyst  is  made  up  of  connective 
tissue  lined  with  epithelial  cells,  like  the  cells  of  the  enamel 
pulp. 

The  contents  of  the  cyst  are  clear  yellow  fluid  containing 
cholesterin  crystals  and  cast-off  epithelial  cells. 

There  is  frequently  a  secondary  infection  of  the  cyst 


Fig.  223. — Root-cyst  of  left  lower  jaw  in  a  nine-year-old  girl  (Perthes). 


The 


(See 


contents,   due  to   the  proximity  of  a  carious  tooth, 
contents  may  be  foul  smelling  if  infected. 

The  root  sometimes  projects  into  the  cyst  cavity. 
Figs.  221,  224.)     The  cyst-wall  may  be  calcined. 

The  origin  of  these  root-cysts  is  from  the  root  granulo- 
mata.  The  root  granuloma  is  a  small  mass  of  granulation 
tissue  attached  intimately  to  the  tooth-root.  The  periphery 
of  the  mass  of  granulation  tissue  is  firmer  than  the  center, 


228 


TUMORS    OF   THE    JAWS 


which  contains  many  more  cells  than  the  periphery.  Some 
of  the  central  cells  are  giant-cells.  There  are  at  times  found 
epithelial,  cylindric  and  stellate  cells,  which  are  the  analogue 
of  the  enamel  organ.  Malassez  regards  them  as  remains  of 
the  epithelial  sheath  of  the  enamel  organ. 


Fig.  224. — -Note  relation  of  cyst  to  antral  floor  and  root  of  tooth  (from  Onodi) : 
sm,  Antrum;  c,  cyst;  ra,  first  molar  tooth. 

The  root-cysts  begin  in  the  center  of  these  granulomata. 
The  normal  epithelial  cells  in  the  center  of  these  granulo- 
mata soften,  break  down,  undergo  fatty  degeneration,  and 
hence  form  the  starting-point  for  the  cyst.  The  primary 
occasion  of  the  granuloma  is  a  periodontitis.  The  sequence, 
then,  of  the  pathology  of  the  root-cysts  is  as  follows :  Some 
irritant  causing  a  periodontitis;  as  a  result  of  the  peri- 


THE    ODONTOMATA 


229 


odontitis  a  granuloma  forms;  this  granuloma  softens  in  the 
center,  and  the  cyst  results. 


Fig.  225. — Diagram  of  three  stages  in  the  development  of  the  root-cyst. 
Note  the  intimate  relation  in  /  of  the  root-cyst  with  the  tooth-root;  in  II, 
the  encroachment  of  the  root-cyst  upon  the  inferior  wall  of  the  antrum;  in 
III,  still  greater  encroachment  of  the  root-cyst  upon  the  antrum  and  also 
upon  the  hard  palate  and  the  nasal  cavity.  S.m.,  Antrum;  c,  cyst  (Perthes). 


These  root-cysts  may  grow  in  various  directions.  If 
they  are  in  the  lower  jaw,  they  present  in  its  outer  side, 
under  the  mucous  membrane.  If  they  appear  in  the  upper 


230 


TUMORS    OF    THE    JAWS 


jaw,  growing  in  the  direction  of  least  resistance,  they  may 
appear  in  any  of  the  cavities  of  the  jaw  or  cavities  of  the 
face,  growing  into  the  antrum,  mouth,  or  nose.  When  the 
cyst  enlarges  into  the  antrum,  it  is  sometimes  mistaken  for 
hydrops  of  the  antrum.  (See  Fig.  225.) 

These  cysts  may  grow  to  an  enormous  size.     The  ordi- 
nary size  is  that  of  a  walnut. 


pm 

Fig.  226. — Note  the  situation  of  a  cyst  at  the  tip  of  the  root  of  a  molar  tooth: 
sm,  Antrum;  c,  cyst',  pm,  root  of  tooth  (from  Onodi). 

A  root-cyst  may  discharge  spontaneously  into  the  nasal 
cavity.  If  the  tooth  at  whose  root  it  is  situated  be  pulled, 
its  contents  willl  be  thus  evacuated.  If  there  is  a  periostitis 
of  the  jaw  near  by,  it  may  become  secondarily  infected. 

Symptoms. — Early,  a  root-cyst  is  symptomless.  Later, 
when  it  attains  some  size,  it  may  make  its  presence  known 


THE    ODONTOMATA 


231 


through  bulging  of  the  antral  wall  or  a  swelling  of  the 
alveolar  process  surrounding  it  or  a  bulging  of  the  hard 
palate.  The  surface  is  smooth  and  bony.  As  the  cyst 
increases  in  size  its  wall  may,  in  being  thinned,  yield  a 
parchment-like  crackle  to  palpation.  Fluctuation  may  be 


Fig.  227. — Note  the  cyst  (c)  depressing  somewhat  the  roof  of  the  mouth 
(p)  and  displacing  upward  the  floor  of  the  antrum  (h).  ci,  Inferior  turbinate; 
mni,  inferior  meatus;  cm,  middle  meatus;  mnm,  middle  turbinate;  sm, 
antrum;  om,  opening  to  nasal  cavity  (from  Onodi). 

obtained  from  the  hard  palate  to  the  outer  wall   of  the 
tumor. 

If  the  teeth  are  displaced  to  one  side,  one  should  have  in 
mind  the  possibility  of  a  root-cyst.  An  exploratory  puncture 
may  be  wise.  An  x-ray,  taken,  as  suggested  by  Perthes, 


232 


TUMORS    OF   THE   JAWS 


with  a  cork  between  the  teeth,  will  be  of  much  diagnostic 
assistance. 

In  diagnosis  it  will  not  be  necessary  to  distinguish  the 
root-cyst  from  a  follicular  or  dentigerous  cyst. 

Central  jaw  tumors  will  be  hard  to  differentiate. 

An  infected  root-cyst  will  be   difficult   to    distinguish 


Fig.  228. — X-ray  of  a  hard  odontoma  of  the 
under  jaw  in  a  girl  eleven  years  old,  with  an  under- 
lying molar  tooth  (Perthes). 


Fig.  229.— X-ray 
of  the  tumor  seen  in 
Fig.  228  after  it  was 
removed,  showing  the 
dense  tissue  and  the 
molar  tooth  (Perthes). 


from  a  localized  periostitis  and  osteitis 
of  the  alveolar  border  of  the  jaw. 

In  the  upper  jaw  one  will  have  to  distinguish  between 
a  collection  of  fluid  in  the  antrum  and  a  tooth-cyst  which 
has  grown  into  the  antrum;  also  between  an  empyema  of  the 
antrum  and  a  suppurating  tooth-cyst  with  perforation  into 
the  antrum.  The  floor  of  the  nose  is  sometimes  raised  in 
cases  of  cyst,  whereas  in  a  simple  empyema  it  is  not  raised. 

Treatment. — Puncture  of  a  root-cyst  rarely  effects  a  cure 
The  Partsch  operation  of  removal  of  a  wall  of  the  cyst  so  as 


THE    ODONTOMATA 


233 


to  lay  the  cavity  of  the  cyst  open  into  the  mouth  is  most 
effective.  The  wall  of  the  cyst  that  projects  should  be 
removed  so  as  to  make  the  part  left  level  with  the  oral  cavity. 
If  the  cyst-wall  is  completely  removed,  there  will  be  no 
recurrence.  Recurrences  occur  when  the  cyst-wall  is  not 
entirely  removed. 


Fig.  230. — Section  through  the  odontoma,  of  which  the  x-ray  is  seen  in  Figs. 
228  and  229:  S,  Enamel;  D,  dentin;  Sp,  enamel  pulp  (Perthes). 

Occasionally,  it  may  be  possible  to  reflect  the  mucous 
membrane  from  off  the  cyst,  incise  it,  remove  the  wall  and 
the  lining,  replace  the  reflected  mucous  membrane,  and 
thus  secure  rapid  healing.  This  result  is  impossible  if  the 
cyst  is  simply  opened  and  packed  with  iodoform  or  other 
gauze. 

Witzel's   trial    of    paraffin  filling  for   these   cysts,    and 


234  TUMORS    OF   THE   JAWS 

Mosetig-Moorhof's   plumbum   of   wax,    have    been    found 
unsatisfactory. 

THE  HARD  ODONTOMATA 

A  tumor  composed  of  tissue  resembling  in  part  a  solid 
hard  tooth  occasionally  occurs.  It  is  an  odontoma.  If 
it  contains  more  of  one  part  of  the  tooth  than  another,  it 
very  properly  might  take  the  name  of  that  tissue  predomi- 
nating, as  a  "cementoma." 


Fig.  231. — An  enlarged  view  of  Fig.  230:  s,  Enamel;  d,  d,  dentin;  si,  stellate 
cells;  c,  cylindric  cells  of  the  enamel  pulp;  6,  connective  tissue  (Perthes). 

Thus  the  classification  of  these  hard  odontomata  accord- 
ing to  Bland-Sutton  is  literally  correct,  but  it  is  difficult, 
without  microscopic  study,  to  arrive  at  a  diagnosis.  Prac- 
tically, such  refinement  in  diagnosis  is  of  little  value.  One 
must  remember  simply  that  the  small  hard  tumors  similar 
to  that  shown  in  Fig.  228  are  odontomata,  and  that  they 
are  most  benign  and  are  best  treated  by  enucleation  and 
complete  removal. 


THE    ODONTOMATA 


235 


> 


Section  through  one-half  the 
tumor. 


Pulp 
cavity 


Dentin          Enamel 


Dentin 


Opposite  half  of  tumor. 
Surface  view. 


Fig.  232. — Hard  odontoma  of  the  lower  jaw  with  a  displaced  molar  tooth. 
Showing  the  gross  microscopic  and  .x-ray  appearances  (Martens,  Konig's 
Clinic,  Berlin). 


Fig.  233.— Hard  odontoma. 
Note  swelling  of  left  cheek.  Arrow 
points  to  tumor  (A.  T.  Cabot, 
Massachusetts  General  Hospital 
series). 


Fig.  234.— Hard  odontoma.  Note 
fullness  of  left  cheek  over  tumor. 
Arrow  points  to  tumor  (A.  T.  Ca- 
bot, Massachusetts  General  Hospital 

series). 


Fig.  235. — An  x-ray  of  a  hard  odontoma.     Note  the  odontoma  at  the  point 

of  the  arrow.     (See  Figs.  233,  234.)     (X-ray  by  Dodd.) 

236 


THE    ODONTOMATA 


237 


Instances  of  exostosis  of  the  jaw  may  clinically  be  mis- 
taken for  the  hard  odontomata.  Suppuration  may  occur 
around  these  adventitious  masses  of  hard  tissue,  and  clini- 
cally they  may  be  mistaken  for  osteomyelitis  of  the  jaw. 


Fig.  236. — Microphotograph  (Brown,  Massachusetts  General  Hospital).     An 
odontoma.     (See  Fig.  237  for  appearances  of  area  within  circle.) 

In  the  removal  of  this  supposedly  carious  focus  it  will 
always  be  important  to  investigate  with  great  care  lest  some 
hard  odontoma  be  overlooked,  and  thus  the  source  of  the 
irritation  not  discovered. 


Case  of  Hard  Odontoma. — A.  M.    A  young  girl  about 
eleven  years  old.     Massachusetts  General  Hospital  clinic. 
General    health    always    fair,    although    never    robust 


238 


TUMORS   OF   THE   JAWS 


One  month  previous  to  operation  she  noticed  a  swelling 
of  the  left  side  of  the  lower  jaw,  as  seen  in  the  photograph 
(Fig.  233).  This  swelling  was  slightly  tender.  Three 
weeks  previously  a  tooth  was  pulled  upon  this  side,  in  the  re- 
gion of  the  swelling.  Two  weeks  ago  the  swelling  was  lanced, 
and  only  blood  was  obtained.  There  has  been  no  pain 


Fig.  237.— Microphotograph  of  tumor,  showing  structure  resembling 
tooth  within  circle  in  Fig.  236.  An  odontoma  (Brown,  Massachusetts 
General  Hospital). 

in  the  swelling,  only  tenderness  to  pressure.  The  tumor 
is  as  hard  as  bone;  at  one  point  it  is  slightly  tender.  The 
alveolar  process  is  enlarged. 

Operation  through  the  gum  and  the  mouth.  Chiseling 
down  to  the  tumor,  a  hard,  ivory-like  mass  popped  out  from 
the  jaw.  The  cavity  from  which  this  came  was  packed 
with  gauze. 


THE    ODONTOMATA  239 

A  year  later  a  tooth  appeared  in  front  of,  and  at  about 
the  seat  of,  the  tumor;  these,  being  carious,  were  removed. 
The  general  health  has  been  only  fair. 

The  x-ray  shows  the  situation  and  the  size  of  the  tumor. 
The  microscopic  section  finds  the  tumor  to  be  an  odontoma, 
the  tumor  resembling  in  structure  a  tooth. 

For  some  months  after  the  operation  in  1901  there  was 
a  swelling  or  thickening  noticeable  to  palpation  at  the  original 
seat  of  the  tumor.  This  gradually  disappeared.  In  July,  1907, 
six  years  after  the  operation,  there  is  no  trouble  with  the 
jaw,  and  excepting  for  carious  teeth  in  both  jaws,  the  girl, 
now  seventeen  years  old,  seems  well. 


BIBLIOGRAPHY  OF  CYSTS  IN  CONNECTION  WITH  THE  TEETH 

Christopher  Heath:    Diseases  of  Jaws. 

W.  P.  Bolles:  Boston  Med.  and  Surg.  Jour.,  September  7,  1841. 

Sir  John  Tomes:  A  System  of  Dental  Surgery,  1887. 

Heisler:    Embryology. 

Eve:   Brit.  Med.  Jour.,  January  6,  1883. 

Broca:  Traite  des  Tumeurs,  vol.  ii,  p.  35. 

J.  Bland  Sutton:    Correct  Embryologic  Classification,  1893. 


CHAPTER  V 
CARCINOMA  OF  THE  JAWS 

CONTENTS  OF  CHAPTER:  Frequency  of  carcinoma  in  the  jaws. — Sex. — Decade. 
— Material  for  study. — Origin  of  carcinoma  of  the  jaws. — Etiology. — 
Relation  of  nasal  polypi. —  Symptoms. —  Metastases. —  Diagnosis. — 
Course  .—Treatment . — Results . 

A  summary  of  cured  cases  from  certain  groups  of  carcinomata  of  the  upper 
jaw. — -Twelve  cases  of  carcinoma  of  the  upper  jaw  operated  upon  at 
the  Massachusetts  General  Hospital  clinic. — :Two  cases  of  carcinoma  of 
the  upper  jaw  operated  upon  at  the  Massachusetts  General  Hospital 
clinic:  Well  today. — Certain  inoperable  carcinomata  of  the  upper  and 
lower  jaws  at  the  Massachusetts  General  Hospital  clinic. — Cases  of  carci- 
noma of  the  lower  jaw  operated  upon  at  the  Massachusetts  General 
Hospital  clinic;  Mortality  of  operation;  Percentage  of  cures. — Carcinoma 
of  the  lower  jaw  at  the  Massachusetts  General  Hospital  clinic;  Cases 
dead  soon  after  operation. — Certain  cases  of  carcinoma  of  the  lower  jaw 
from  the  Massachusetts  General  Hospital  clinic.  Died  from  recur- 
rence.— Carcinoma  of  the  lower  jaw  operated  upon  at  the  Massachusetts 
General  Hospital  clinic.  Six  cases  alive  today. — The  statistics  of  carci- 
nomata of  the  upper  and  lower  jaws  from  the  Boston  City  Hospital 
clinic. — Meller's  report  of  cases  of  carcinoma  of  the  lower  jaw. — The 
prognosis  of  carcinoma  of  the  jaws. — Table  of  percentage  mortality 
following  total  and  partial  resection  of  the  jaws  from  various  clinics. 


Frequency. — Carcinoma  is  more  frequent  in  the  upper 
and  lower  jaws  than  sarcoma.  About  three  cases  of  car- 
cinoma occur  to  two  of  sarcoma.  Taking  the  cases  re- 
corded from  the  clinics  at  Vienna,  Gottingen,  Prague,  Berlin, 
Zurich,  Wiirzburg,  Erlangen,  and  Berlin  recorded  by  Stein, 
there  were  of  upper  jaw  carcinomata,  330  cases:  sarcomata, 
225  cases;  of  lower  jaw  carcinomata,  204  cases:  sarcomata, 
122  cases. 

In  the  Massachusetts  General  Hospital  clinic  there  were : 
Of  upper  jaw  carcinoma,  16  cases;  sarcoma,  15  cases;  of 
lower  jaw  carcinoma,  27  cases;  sarcoma,  16  cases. 

Sex. — Carcinoma  of  the  jaws  occurs  more  frequently 

240 


CAKCINOMA   OF   THE   JAWS 


241 


among  men  than  among  women.  In  four  general  surgical 
clinics  where  accurate  records  were  kept  204  men  were 
affected  and  78  women.  Of  the  40  cases  of  cancer  of  the 
lower  jaw  studied  by  Warren,  Greenough,  etc.,  from  the 


Fig.  238. — Carcinoma  of  upper 
jaw.  Middle  and  superior  turbinates 
not  involved.  Origin  from  antrum. 
The  roof  of  the  mouth  was  involved. 
m.t.,  Middle  turbinate;  n.p.s.m.,  na- 
sal process  of  superior  maxilla;  i.n., 
infra-orbital  nerve  (Warren  Museum, 
No.  9736). 


Fig.  239. — Carcinoma  of  upper 
jaw.  Buccal  mucosa  uninvolved. 
Origin  in  the  antrum:  n.p.s.m.,  Nasal 
process  superior  maxilla;  i.n.,  infra- 
orbital  nerve;  i.ridge,  infra-orbital 
ridge  (Warren  Museum,  No.  9736). 


Massachusetts  General  Hospital  clinic,  32  were  males  and 
8  females — a  ratio  of  4  to  1. 

Decade. — Carcinoma  occurs  definitely  at  a  later  period 
of  life  than  either  sarcoma  or  epulis.     The  cases  occurring 
at  different  ages  (decades)  have  been  charted.     The  chart 
16 


242 


TUMORS    OF    THE    JAWS 


is  most  striking.     Carcinoma  of  the  jaw  is  most  commonly 
seen  in  the  two  decades  between  fifty  and  seventy. 


Fig.  240. — Carcinoma  of  upper  jaw  starting  in  the  antnirn. 


Fig.  241. — Same  case  as  seen  in  Fig.  240. 

Cases  recorded  by  Birnbaum,  Balzaroff,  Martens,  Stein, 
Behm,  and  Schmidt  are  here  charted. 


CARCINOMA    OF    THE    JAWS 


243 


At  the  Massachusetts  General  Hospital  clinic  there  were 
44  cases  of  carcinoma  of  the  jaws.  It  is  this  material  which 
forms  the  basis  of  this  chapter. 

There  were  16  cases  of  upper  jaw  carcinoma  and  28 
cases  of  lower  jaw  carcinoma.  Of  these  44  cases,  33  were 
males  and  11  were  females — a  ratio  of  3  to  1.  Men  are  more 
liable  to  carcinoma  of  the  jaw  than  women. 

A  TABLE  BASED  UPON  176  CASES  OF  CARCINOMA,  148  CASES  OF 
SARCOMA,  AND  167  CASES  OF  EPULIS  OF  THE  JAWS 


50 


10 


L 


L 


L 


\ 


\ 


\ 


\ 


\ 


\ 


60 


70 


80        30  years 


Fig.  242. — Heavy  line,  frequency  of  carcinoma  at  the  different  decades 
of  life.  Light  line,  frequency  of  sarcoma  at  the  different  decades  of  life. 
Dotted  line,  frequency  of  epulis  at  the  different  decades  of  life. 

As  the  accompanying  charts  graphically  show,  the 
time  of  the  maximum  appearance  of  carcinoma  is  at  a 
strikingly  different  decade  from  that  at  which  sarcoma  ap- 
pears to  grow.  This  curve,  derived  from  the  Massachusetts 
General  Hospital  clinic,  is  quite  similar  to  that  from  other 
combined  clinics.  It  demonstrates  that  the  sarcoma  time 
of  growth  is  at  an  earlier  age  than  the  carcinoma  time  of 
growth.  Carcinoma  flourishes  between  forty  and  sixty 


244 


TUMORS    OF   THE   JAWS 


years, — in  the  middle  and  later  period  of  life, — while  sar- 
coma selects  youth  and  middle  life — from  ten  to  fifty  years— 
in  which  to  develop. 


CURVES    SHOWING    RELATIVE    FREQUENCY    OF    CARCINOMA 
AND  SARCOMA  AT  VARIOUS  DECADES  IN  THE  MASSACHU- 
SETTS GENERAL  HOSPITAL  SERIES 


Decade 


Fig.  243. — Dotted  line,  sarcomata  of  the  jaws  (upper  and  lower).     Solid  line, 
carcinomata  of  the  jaws  (upper  and  lower). 


Origin  of  Carcinoma  of  the  Jaws. — If  we  consider  for 
clinical  purposes  the  gums  and  the  mucous  membrane  over 
the  upper  and  lower  jaw,  alveolar  surfaces,  and  palate  as  a 


CARCINOMA    OF    THE    JAWS  245 

part  of  the  jaw  itself,  then  carcinoma  may  be  said  properly 
to  be  primary  when  it  starts  from  these  sources. 

There  is,  of  course,  no  carcinoma  primary  in  the  bone  it- 
self. All  carcinomata  of  the  jaw  start  in  tissues  outside  the 
bone  and  invade  the  jaw  secondarily. 

The  central  carcinoma  of  the  upper  jaw  starts  usually  in 
the  mucous  membrane  of  the  antrum  of  Highmore.  The 


Fig.  244. — Carcinoma  of  the  lower  jaw.  Note  the  involvement  of  the 
bone  in  the  growth.  Note  the  fracture  of  the  jaw  at  the  center  of  the  growth 
i  Warren  Museum). 

type  of  central  carcinoma  is  usually  the  cylindric-cell  form. 
Martens  thinks  that  squamous-cell  cancer  may  arise  from 
the  antrum.  Killian  suggests  that  the  origin  of  carcinoma 
from  the  tooth-root  alveoli  is  explicable  on  the  basis  of  its 
starting  from  paradental  epithelial  rests,  which  are  known  to 
exist  there. 

The  central  carcinoma  of  the  lower  jaw,   without   in- 


246  TUMORS    OF    THE    JAWS 

volvement  of  mucous  membrane  of  the  gum,  is  unknown. 
Carcinoma  of  the  lower  jaw  always  starts  from  the  ulcera- 
tion  of  the  mucous  membrane  or  contiguous  parts,  that  is, 
of  the  cheek,  salivary  glands,  face,  neck,  lip,  or  tongue. 
The  cancer  of  the  upper  jaw  which  is  most  common 


Fig.  245. — Man,  sixty  years  old.  Bones  of  face  involved  in  the  destruc- 
tive advance  of  carcinoma  (Army  Medical  Museum,  Washington,  D.  C., 
Xo.  9780). 

starts  not  centrally,  but  from  the  mucous  membrane  of  the 
cheek  and  nose. 

It  is  very  unusual  to  find  metastatic  carcinoma  in  the 
jaws.  Batzaroff,  from  the  Zurich  clinic,  reports  two  cases 
in  which,  following  carcinoma  of  the  breast,  carcinoma  de- 
veloped in  the  upper  jaw  in  one  case  and  in  the  lower  jaw  in 


PLATE  V 


Lower  jaw  involved  in  the  ulceration  of  carcinoma.     Note  the  worm-eaten 
appearances  of  the  bone.      (Painting  by  Florence  Byrnes.) 


CARCINOMA    OF    THE    JAWS 


247 


the  other  case.  These  metastases  occurred  one  and  three- 
quarter  years  after  the  breast  was  removed.  There  had 
been  no  recurrence  in  the  breast. 


Fig.  246. — Sarcoma  of  lower  jaw,  ossifying  type.  Woman,  aged  twenty- 
one  years.  Patient  died  two  and  one-half  months  after  the  appearance  of 
the  disease  (Army  Medical  Museum,  Washington,  D.  C.,  No.  5255). 

Riedel  records  a  case  of  metastasis  of  carcinoma  of  the 
thyroid  to  the  lower  jaw.     This  is  a  unique  experience. 
Etiology. — Little  or  nothing  is  known  of  the  etiology  of 


248 


TUMORS   OF   THE   JAWS 


carcinoma.  Carcinoma  of  the  jaws  is  often  associated  with 
some  form  of  chronic  irritation.  That  carcinoma  in  many 
parts  of  the  body  is  antedated  by  some  form  of  chronic  irri- 
tation is  coming  to  be  more  and  more  generally  accepted  as 
one  fact  of  importance  in  the  etiology.  In  many  cases  the 
smoking  of  a  pipe  for  years  is  thought  to  have  been  the  reason 
for  the  carcinoma  appearing  in  an  ulcer  of  the  gum  of  the 


Fig.  247. — Case  E.  T.,  fifty-seven  years  old.  Carcinoma  of  alveolar 
margin  of  upper  maxilla.  Partial  resection  after  one  year's  duration  (F.  B. 
Harrington). 

alveolar  margin.  The  danger  of  local  irritation  continued 
over  a  long  period  of  time  is  very  greatly  minimized  popu- 
larly, and  even  among  physicians. 

Again,  carcinoma  sometimes  follows  in  the  sinus  or 
edges  of  old  fistulous  tracts  about  the  jaws.  The  base  of  a 
syphilitic  ulcer  may  become  cancerous. 


CARCINOMA    OF    THE    JAWS 


249 


At  the  Leipsic  clinic  a  case  was  seen  that  was  thought  to 
be  due  to  an  implantation  of  cancer  from  a  tongue  to  the 
jaw,  from  contact — a  decubitus  ulcer. 

Cancer  of  the  lower  jaw  is  oftentimes  secondary  to  cancer 
of  the  floor  of  the  mouth,  of  the  tongue,  of  the  lip,  of  the 
parotid,  and  of  the  submaxillary  region. 

Relation  of  Nasal  Polypi  to  Carcinoma. — It  is  not 
unusual  to  find  a  history  of  nasal  polypi  having  been  re- 


Fig.  248. — Carcinoma  of  left  upper  jaw.     Man,  thirty-nine  years  old.     Ex- 
tensive ulcerations  in  nose  (F.  W.  Dudley,  Manila,  P.  I.). 

moved,  possibly  several  times  removed,  and  that  subse- 
quently malignant  disease  of  the  nose  and  jaw  appeared. 
The  question  of  the  relation  of  nasal  polypi  to  malignant 
disease  is  yet  undetermined.  A  nasal  polypus  ordinarily  is 
an  edematous  tab  of  mucous  membrane  which  is  associated 
with  some  subacute  inflammatory  process.  Theoretically, 
it  would  seem  most  likely  that  the  malignant  process  is 


250  TUMORS   OF   THE   JAWS 

primary,  and  the  polypi  are  simply  secondary  to  the  malig- 
nancy. 

Simultaneous  involvement  '  of  both  superior  maxillae 
with  cancer  is  possible,  but  is  rarely  met. 

In  1903  Darnell  collected  from  the  literature  79  primary 
carcinomata  of  the  nasal  fossae  and  accessory  cavities. 

Trautman  says,  according  to  Maljutin,  that  the  antrum 
is  the  commonest  seat  of  beginning  malignant  growths, 


Fig.  249. — Carcinoma  of  the  alveolar  arch  and  hard  palate  (after  Perthes). 

while  von  Donogany  asserts  that  the  middle  turbinate  must 
be  awarded  the  first  place  as  origin. 

Neoplasms  arising  in  the  antrum  may  give  rise  to  symp- 
toms of  empyema  of  the  antrum.  There  is  no  distinctive 
symptom  until  the  growth  breaks  through  the  bony  wall, 
which,  according  to  Schwenn,  is  proof  of  malignancy. 

Carcinoma  of  the  orbit  arises  from  the  lacrimal  gland  or 
the  conjunctiva. 


CARCINOMA    OF    THE    JAWS 


251 


Symptoms  of  Carcinoma  of  the  Jaws. — The  anatomic 
position  of  the  growth  determines  somewhat  the  character 
of  the  early  symptoms,  for,  as  a  rule,  these  symptoms  are 
manifestations  of  pressure.  Therefore,  if  the  new-growth 
extends  without  causing  pressure,  there  may  be  no  symp- 
toms whatever  until  the  involvement  of  the  jaw  has  become 


Fig.  2oO. — Carcinoma  of  the  alveolar  processes  of  the  upper  jaw.     Note  the 
ulceration  on  the  left  side  (from  Mikulicz's  Atlas.  1892). 

very  extensive.  Pain,  deep  seated  and  dull,  or  neuralgic  in 
character,  or  like  a  toothache,  usually  in  the  bicuspid  or 
molar  tooth,  may  be  considered  as  one  of  the  earliest  and 
most  common  symptoms  of  malignant  disease  of  the  maxilla 
starting  in  the  alveolar  process.  Not  infrequently  this  pain 
leads  to  the  extraction  of  the  painful  tooth,  of  course  without 
relief.  Examination  at  the  time  of  extraction  may  disclose 


252 


TUMORS    OF    THE    JAWS 


a  pathologic  condition  of  the  alveolar  process.  Adjacent 
teeth  are  found  loosened,  and  are  usually  subsequently 
extracted.  If  nothing  positive  is  discovered,  there  may 
follow  a  daily  discharge  of  a  few  drops  of  clear  or  sero- 
purulent  fluid  from  the  tooth-socket,  and  a  little  later  a 
new-growth  will  be  noticed  invading  the  alveolar  process 
from  the  tooth-socket. 


Fig.  251. — Carcinoma  of  the  right  upper  jaw  (Trendelenburg) . 

The  pain,  from  the  nature  of  the  pressure,  may  be  located 
either  in  the  ear,  from  obstruction  of  the  Eustachian  tube, 
or  in  the  temporomaxillary  articulation.  The  pulling  of  the 
teeth  may  attract  attention  to  that  particular  part,  and  a 
mass  or  tumor  be  noticed  exactly  at  the  time  the  teeth  are 
extracted. 

Almost  as  early  and  common  a  symptom  as  pain  is  the 
bulging  of  the  antral  wall.  If  it  is  borne  in  mind  that  the 
antrum  is  a  three-sided  pyramid,  bounded  by  the  orbital, 


CARCINOMA   OF   THE   JAWS 


253 


zygomatic,  and  facial  surfaces  of  the  superior  maxillary 
bone,  with  the  outer  wall  of  the  nasal  cavity  as  a  base,  it 
will  readily  be  seen  where  this  deformity,  due  to  the  bulging 
or  breaking  down  of  the  walls,  will  be  manifested. 

That  is,  if  the  growth  extends  anteriorly,  there  will  be 
noticed  a  bulging  of  the  cheek;    that  side  of  the  face  is 


Fig.  252. — Carcinoma  of  antrum,  secondary  to  nasal  polypi.  White 
male,  aged  forty-one  years.  Nasal  polypus;  symptoms  for  seven  months. 
Photograph  taken  one  year  after  disease  was  detected.  The  patient  died 
six  months  later  (from  original,  loaned  by  Joseph  C.  Bloodgood). 

broadened,  and  the  nose  is  pushed  toward  the  opposite 
side,  or,  in  case  of  a  rapid  extension  of  the  growth  anteriorly, 
an  ulcer  of  the  cheek  may  appear,  not  associated  with  great 
pain,  which,  from  its  painless  character,  has  been  confused 
with  syphilis  and  with  a  necrosis  of  bone  due  to  an  infection. 
(See  Figs.  253,  255,  257.) 


254 


TUMORS    OF    THE    JAWS 


Extension  upward  may  cause  a  disturbance  of  vision* 
due  to  such  intra-orbital  pressure  as  to  cause  an  increased 
intra-ocular  tension,  or  an  actual  extrusion  of  the  eyeball 
may  result.  (See  Fig.  251.)  Fullness  may  also  be  noticed  in 
the  temporomaxillary  fossa,  and  at  times  there  is  difficulty 
in  mastication. 


Fig.  253. — Carcinoma  of  the  upper  jaw;  man,  forty-one  years  old,  thought 
to  be  necrosis  of  the  bone  of  the  superior  maxilla  because  of  a  sinus  in  the  cheek 
discharging  bits  of  bone.  Note  the  pallor,  swelling  of  right  cheek,  obliteration 
of  the  right  superior  nasolabial  fold. 

Extension  toward  the  base  of  the  pyramid  will  cause 
obstruction  of  the  nasal  cavity,  and  this  plugging  of  the 
nares  is  perhaps  even  a  more  frequent  symptom  than  either 
pain  or  evident  bulging  of  the  antral  walls  outward.  One- 
sided nasal  obstruction,  associated  with  the  discharge  of 


Fig.  254. — Man,  seventy  years  old.     Rodent  ulcer  which  had  existed  seven 
years,  destroying  nearly  one-half  of  the  face  (Kaposi). 


Fig.  255. — Ulcerating  carcinoma  of  the  upper  jaw  (Schlatter). 
255 


256  TUMORS    OF    THE    JAWS 

bloody  fluid  and  combined  with  pain  of  a  neuralgic  character 
or  a  feeling  of  fullness  in  the  antrum,  is  a  most  suggestive 
combination  of  symptoms.  A  growth  may  protrude  from 
the  nostril,  and  if  not  from  the  nostril,  from  some  accessory 
sinus,  into  the  inferior  or  middle  meatus.  Repeated  slight 
hemorrhages  from  the  nose  occur. 


Fig.  256. — Mrs.  A.     Carcinoma  of  the  upper  jaw. 

Obstruction  of  the  tear-duct  and  edema  of  the  lower  lid 
are  additional  signs  which  often  result  from  this  involvement 
of  the  wall  of  the  antrum. 

In  times  past  the  involvement  or  non-involvement  of  the 
adjacent  lymphatics  was  often  emphasized,  and  considered 
in  the  differential  diagnosis  between  benign  and  malignant 
growths  of  the  upper  jaw.  The  more  recent  observations, 


CARCINOMA   OF   THE    JAWS 


257 


particularly  those  of  Martens,  which  have  been  corroborated 
by  Butlin,  show  that  lymphatic  involvement  with  malignant 
disease  in  this  location  is  a  very  late  rather  than  an  early 
manifestation. 

Ulcerations  within  the  mouth,  while  they  may  commonly 
be  benign  in  nature  or  associated  with  a  specific  infection, 


Fig.  257. — -Mrs.  A.     Carcinoma  of  the  upper  jaw.     Note  the  ulcerating  mass. 

are  to  be  considered  as  danger-signals  and  examined  at  the 
earliest  possible  moment.  Ulcers  of  the  gum  which  involve 
the  bone  subsequently  are  in  the  early  stages  amenable  to 
treatment  by  complete  local  excision  with  a  wide  margin  of 
sound  bony  tissue. 

Many  times  carcinoma  of  the  jaw,  particularly  of  the 
17 


258  TUMORS   OF   THE   JAWS 

upper  jaw,  begins  as  a  superficial  ulcer  of  the  skin  of  the 
face.  An  ulcer  with  this  origin  increases  gradually,  but  it 
increases,  nevertheless.  Such  an  ulcer  may  be  mistaken  for 
necrosis  of  the  jaw.  There  is  usually  little  pain  associated 
with  this  growth,  as  it  invades  the  bone  from  the  cheek. 

Metastases. — Cancer  of  the  lower  jaw  forms  metastases 
more  often  and  earlier  than  cancer  of  the  upper  jaw.     The 


Fig.  258. — Mrs.  A.  Carcihoma  of  the  upper  jaw,  starting  in  the  ant  rum 
of  Highmore.  Note  that  the  inferior  turbinate  bone  is  uninvolved  in  the 
disease.  Complete  excision  of  the  upper  jaw  was  done,  together  with  removal 
of  the  contents  of  the  orbit.  Recurrence.  Death.  (See  Fig.  256.) 

submaxillary  and  deep  cervical  glands  may  be  invaded  by 
growths  in  either  upper  or  lower  jaws.  The  parotid  lym- 
phatic glands  are  usually  invaded  from  the  upper-jaw 
growths.  The  submental  glands  are  invaded  by  lower-jaw 
growths.  Cancer  of  the  upper  jaw  gives  glandular  metas- 
tases late. 


CARCINOMA    OF    THE    JAWS 


259 


Diagnosis. — Inflammatory  disturbances  in  the  antrum 
of  Highmore  may  be  associated  with  carcinoma  of  that  part. 

The  ulcerations  upon  the  gums  or  alveolar  borders  which 
may  be  mistaken  for  carcinoma  are  the  ulceratlons  of  tuber- 
culosis, actinomycosis,  and  tertiary  syphilis. 

Course. — The  course  of  carcinoma  of  the  jaws  is  a  rapid 
one.  As  cases  present  themselves  to  the  surgeon  they  often 
are  inoperable,  even  from  a  palliative  standpoint.  Death 
usually  ensues  within  two  years  ^^^^^««— 

after  the  appearance  of  the  dis- 
ease. 

Treatment. — If  the  disease 
is  well  advanced,  a  total  ex- 
cision of  the  upper  jaw,  together 
with  a  thorough  search  through 
the  various  sinuses  accessory  to 
the  nasal  cavity,  is  indicated. 
Partial  excision  may  be  more 
safely  tried  for  localized  car- 
cinoma of  the  upper  jaw  than 
of  the  lower  jaw. 

There  is  greater  risk  of 
recurrence  in  doing  a  partial 
operation  upon  the  lower  jaw  than  there  is  from  partial 
operation  upon  the  upper  jaw.  In  a  very  early  carcinoma 
of  the  alveolar  process  of  the  upper  jaw  a  partial  operation 
may  be  wise. 

A  partial  operation  on  the  lower  jaw  is  attended  with 
great  risk  of  incomplete  removal.  An  exarticulation  or  re- 
section in  continuity  of  the  lower  jaw  is  the  wisest  procedure 
if  the  carcinoma  is  well  developed. 


\ 


•? 


Fig.  259. — Carcinoma  at 
symphysis  of  the  lower  ia\v. 
Woman,  forty-five  years  old  (F. 
W.  Dudley,  Manila,  P.  I.). 


260  TUMORS    OF    THE    JAWS 

Results. — The  results  of  treatment  of  the  upper  jaw 
carcinomata  in  general  are  disappointing.  The  returns  are 
made,  in  the  cases  collected  by  Martens,  upon  the  basis  of  a 
three-year  immunity. 

Martens  collects  49  cases  from  the  literature  (recorded 
by  Ohlemann,  Kiister,  Birnbaum,  Braun,  von  Winiwarter, 
Batzaroff,  and  von  Petzold),  of  which  only  2  are  well.  Both 
of  these  cases  were  from  the  Zurich  clinic,  and  had  been 


Fig.  260. — Carcinoma  of  symphysis.  Extensive  ulceration  in  floor  of 
mouth.  Foul  odor.  Woman,  forty-five  years  old  (see  Fig.  259)  (F.  W.  Dud- 
ley, Manila,  P.  I.). 


operated  upon  by  von  Kronlein.  One  died  five  years  eight 
months,  the  other  died  seven  years  two  months,  following 
operation,  without  recurrence. 

In  the  statistics  of  von  Stein,  recording  the  cases  of  the 
Berlin  clinic  for  the  years  1890  to  1900,  there  were  13  cases 
followed.  No  one  of  these  cases  was  alive.  Ten  died  of 
recurrence  in  from  three  to  nine  months  following  operation. 


CARCINOMA    OF    THE    JAWS 


261 


Fuchs  reports  from  the  Breslau  clinic  23  cases  of  car- 
cinoma of  the  upper  jaw  during  the  years  1891  to  1901. 
None  was  free  from  recurrence  three  years  after  operation. 

Martens  reports  Konig's  experience  at  the  Gottingen 
clinic:  of  48  total  upper  jaw  resections,  29  survived  the 
operation.  There  were  19  operative  deaths — 39  per  cent. 
Eight  cases  were  found  free  from  recurrence  after  three  years 
had  passed  since  the  opera- 
tion. 

Nine  partial  operations 
were  done.  Six  died  of  re- 
currence. Three  cases  were 
very  recently  operated  upon. 
These  8  cured  cases  of  cancer 
of  the  upper  jaw  remained 
cured  respectively  five  years 
two  months,  seven  years  six 
months,  nine  years  nine 
months,  twelve  years  one 
month,  ten  years  three  and 
one-half  months,  and  eighteen 
years  three  months,  after  op- 
eration. A  later  report  of  these  8  cases  shows  that  2  have 
died  of  some  other  ailment,  leaving  6  now  living.  Taking 
both  the  upper  and  lower  jaw,  there  were  21  deaths  from 
recurrence  of  the  disease. 

Martens  records  one  case  of  partial  resection  of  the 
upper  jaw  for  carcinoma  well  five  years  and  nine  months 
following  operation. 

The  Gussenbauer  clinic  records  the  following:  32  cases 
of  carcinoma  of  the  upper  jaw:  29  cases  have  been  followed 


Fig.  261. — Carcinoma  of  left 
lower  jaw.  Ulcerating  mass  in 
mouth.  Woman,  forty-four  years 
old  (F.  W.  Dudley,  Manila,  P.  I.). 


262 


TUMORS    OF    THE    JAWS 


subsequent  to  operation;  3  have  had  1  recurrent  operation; 
2  have  had  2  recurrent  operations ;  8  died  of  recurrence  from 
four  to  eleven  and  one-half  months  after  the  primary  opera- 
tion; 16  died  of  recurrence  from  two  and  one-half  to  thirty- 
six  months  after  the  primary  operation;  3  died  without  re- 
currence, of  some  other  disease,  three  years  four  and  one-half 


Fig.  262. — Carcinoma  of  the 
lower  jaw.  Early  recurrence  in  ci- 
catrix  after  attempted  removal. 


Fig.  263. — Carcinoma  of  the 
lower  jaw.  Illustrating  a  badly  placed 
incision  from  the  angle  of  the  jaw. 


months  to  three  years  six  months  after  operation;  2  are 
well  and  living  since  operation — one  five  years,  and  the  other 
over  one  and  one-half  years  since  operation.  The  average 
time  of  death  after  operation  was  fourteen  months. 

Unoperated  cases  of  cancer,  that  is,  inoperable  carcino- 
mata,  live,  after  being  seen  by  the  surgeon,  about  ten  months. 


CARCINOMA    OF    THE    JAWS  263 

A   SUMMARY  OF   CASES   FROM  CERTAIN   GROUPS  OF 
CARCINOMATA  OF  THE  UPPER  JAW 

Occurrence  at  the  Massachusetts  General  Hospital  Clinic.— 
Twelve  cases  were  operated  upon:  2  cases  are  well,  each 
seven  years  after  operation. 

Occurrence  at  the  Zurich  Clinic  (Kronlein). — Two  cases 
well,  1  died  five  years  eight  months  after  operation,  and  1 
died  seven  years  two  months  after  operation. 


Fig.  264. — The  remains  of  the  lower  jaw  undestroyed  by  primary  cancer 
of  the  lower  lip.  The  lip  was  removed.  Recurrence  in  lower  jaw;  bone 
destroyed;  fatal  hemorrhage  (specimen  from  Warren  Museum,  No.  1526). 


Reported  by  von  Stein,  1890-1900  (Berlin)  .—Thirteen 
cases:  all  are  dead. 

Reported  by  Fuchs  (Breslau),  1891-1901.— Twenty- 
three  cases:  none  are  without  recurrence  after  a  three-year 
period. 

Reported  by  Konig  (Gottingen). — Forty-eight  cases:  8 
cases  are  well  after  three  years,  i.  e.,  17  per  cent,  of  the  cases 
were  "cured." 


264  TUMORS    OF   THE   JAWS 

The  time  which  has  elapsed  since  operation  in  the  8  cases 
operated  upon  by  Konig  is  as  follows : 

1.  5  yrs.  2  mos.  5.     9  yrs.  9  mos. 

2.  7  yrs.  6  mos.  6.  12  yrs.  1  mo. 

3.  9  yrs.  7  mos.  7.  10  yrs.  3^  mos. 

4.  9  yrs.  7  mos.  8.  18  yrs.  3  mos. 

•A  microscopic  examination  was  made  in  each  of  these 
cases  of  Konig,  and  the  reports  are  as  follows: 

1.  Alveolar  adenocarcinoma. 

2.  Squamous-cell  carcinoma. 

3.  Squamous-cell  carcinoma. 

4.  Epithelial  tumor  with  alveolar  structure. 

5.  Adenocarcinoma  with  alveolar  structure. 

6.  Adenocarcinoma  with  alveolar  structure. 

7.  Squamous-cell  carcinoma. 

8.  Squamous-cell  carcinoma. 

Reported  by  Gussenbauer. — Thirty-two  cases  have  been 
followed  to  date:  2  are  well — 1  five  years  after  operation 
and  1  one  and  one-half  years  after  operation. 

This  makes  a  total  from  these  different  clinics  of  177  cases 
of  carcinoma  of  the  upper  jaws  operated  upon.  Thirteen 
of  these  cases  remained  well  for  three  years  and  over  follow- 
ing operation.  This  is  equivalent  to  7.5  per  cent,  of  " cures." 

Twelve  cases  of  carcinoma  of  the  upper  jaw  were  oper- 
ated upon  at  the  Massachusetts  General  Hospital  clinic:  1 
case  was  not  traced;  9  cases  have  been  traced  and  all  have 
died.  There  were  no  deaths  from  operation  in  this  series. 
Two  cases  are  well  today. 

TIME  OF  DEATH  FOLLOWING  OPERATION  FOR    CARCINOMA 

OF  THE  UPPER  JAW  AT  THE  MASSACHUSETTS 

GENERAL  HOSPITAL  CLINIC 

12.  R.  E.  Died  one  year  and  three  months  after  opera- 
tion. 


CARCINOMA    OF    THE    JAWS 


265 


19.  M.  H.  Complete  excision.  Died  one  year  two  and 
one-half  months  after  operation. 

22.  L.  P.  Complete  excision  with  enucleation  of  eye. 
Died  four  years  and  six  months  after  operation. 

24.  H.  W.  Complete  operation.  Died  six  and  one-half 
months  after  operation. 


Fig.  265. — Inoperable  carcinoma  of  the  jaw.  Note  the  extensive  ulcera- 
tion  of  the  soft  parts  and  bone  (Massachusetts  General  Hospital,  out-patient 
clinic). 

26.  W.  P.     Died  three  months  after  operation. 

27.  M.    B.     Complete    operation.     Died    five    months 
after  operation. 

39.  S.  H.  Complete  upper  jaw  resection  and  partial 
lower  jaw  resection.  Died  one  year  and  three  months  after 
operation. 

43.  M.  S.  Complete  operation.  Died  six  and  one-half 
months  after  operation. 


266  TUMORS    OF   THE   JAWS 

44.  O.  E.     Complete  operation.     Died  ten  and  one-half 
months  after  operation. 


Two  Cases  of  Carcinoma  of  the  Upper  Jaw  Operated 
Upon  at  the  Massachusetts  General  Hospital 

Clinic :  Well  Today 

25.  W.  M.  Forty-one  years  old.  Thirteen  years  pre- 
viously a  small  growth  appeared  below  the  left  eye.  Two 
years  ago  this  growth  rapidly  increased  in  size.  It  was 


Fig.  266. — Carcinoma  of  left  lower  jaw.     Woman,  fifty-five  years  old.     Late 
ulcerations  (F.  W.  Dudley,  Manila,  P.  I.). 

cureted.  It  was  thought  to  be  associated  with  a  necrosis  of 
the  jaw.  When  the  man  presented  himself  for  operation 
there  was  a  hard  mass,  the  size  of  a  silver  dollar,  beneath  the 
left  eye,  pushing  up  the  lower  lid.  The  eye  was  half  closed. 
This  mass  was  ulcerated.  Operation  by  S.  J.  Mixter. 
An  excision  of  the  mass,  together  with  a  portion  of  the  malar 
bone  and  the  floor  of  the  orbit.  Microscopic  examination 
showed  an  infiltrating  carcinoma.  This  man  was  alive  and 
well  seven  years  after  operation. 


CARCINOMA   OF  THE   JAWS  267 

28.  R.  J.  B.  Sixty-six  years  old.  Eight  weeks  ago  he 
complained  of  pain  in  the  left  ear,  eye,  and  the  side  of  the 
head.  Six  weeks  ago  a  tumor  began  to  form  in  the  region  of 
the  left  cheek.  Four  weeks  ago  this  tumor  appeared  in  the 
roof  of  the  mouth  and  kept  him  awake  on  account  of  pain. 
Examination  discloses  a  firm,  elastic  tumor  on  the  left 
cheek,  pushing  the  nose  to  the  right,  projecting  into  the 
mouth,  extending  into  the  left  nostril,  pushing  the  septum  to 
the  right.  Operation  was  done  by  Dr.  J.  W.  Elliot.  Com- 
plete removal  of  the  upper  jaw.  The  antrum,  the  left  nostril, 
and  the  ethmoid  cells  were  involved  in  the  growth.  Micro- 
scopic examination  was  an  alveolar  carcinoma.  Seven  years 
after  operation  this  patient  was  alive  and  well. 

CERTAIN  INOPERABLE  CARCINOMATA  OF  THE  UPPER  AND 

LOWER  JAWS  AT  THE  MASSACHUSETTS  GENERAL 

HOSPITAL  CLINIC 

1.  J.   M.     Sixty-eight    years    old.     Male.     Left    lower 
alveolar  border,  bicuspid  to  molar,  ulcerating,  stinking  mass. 
Submaxillary   glands   enlarged.     Duration,    three   months. 
Lived  two  years  seven  months  after  operation  was  refused. 

2.  M.  G.     Sixty-three  years  old.     Female.     Left  lower 
alveolar  border,  second  bicuspid  to  the  ascending  ramus, 
involving  left  tonsil  and  side  of  the  tongue.     Duration,  six 
months.     Lived  four  months  after  operation  was  refused. 

3.  C.W.     Fifty  years  old.     Male.     Right  cheek,  mucous 
membrane,  superior  and  inferior  alveolar  borders,  hard  and 
soft  palates  involved.     No  distinct  glands  felt  in  the  neck. 
Duration,  ten  and  one-half  months.     Lived  six  months  after 
operation  was  refused. 

4.  E.  K.     Forty-three  years  old.     Female.     Upper  right 
alveolar  process  ulceration  of  gum  and  anterior  pillar  in- 
volved.   Enlarged  cervical  glands.    Duration,  twelve  months. 
Lived  eleven  months  after  operation  was  refused. 

5.  P.  H.     Seventv-five  years  old.     Female.     Left  nasal 


268  TUMORS    OF    THE    JAWS 

cavity.  Nostril  blocked.  Polypi  removed.  Bleeding.  Neu- 
ralgia in  ear  and  head.  Duration,  several  years.  Lived 
four  and  one-half  months  after  operation  was  refused. 

6.  S.  D.  Thirty-nine  years  old.  Male.  Ulcerated 
tooth,  loosened,  was  extracted.  Right  upper  molar  and  bi- 
cuspids involved,  across  hard  palate  to  incisors.  Duration, 
seven  months.  Lived  a  few  months  after  operation  was 
refused. 


Fig.  267. — Carcinoma  of  the  lower  jaw  on  the  left  side.  Note  external 
swelling.  Note  mass,  just  faintly  visible,  appearing  in  mouth  between  lips. 
Note  edema  and  infiltration  of  the  cheek;  also  fullness  in  submaxillary  region. 
Not  operated  upon  (Massachusetts  General  Hospital,  out-patient  clinic). 

7.  G.  N.     Forty  years  old.     Male.     Lower  lip  and  sub- 
maxillary  tumor,  right  side,  size  of  an  orange.     Painless. 
Duration,  five  and  one-half  months.     Partial  resection  done 
of  lower  jaw.     Six  months  later  recurrence  involving  phar- 
ynx, considered  inoperable.     Lived  six  months  after  opera- 
tion was  refused. 

8.  E.  L.^   Eighty-seven     years     old.     Female.     Tumor 
size  of  an  orange  bulging  palate  and  involving  the  fauces. 


CARCINOMA    OF    THE    JAWS 


269 


Duration,    two    months.     Lived    three    and    three-quarter 
months  after  operation  was  refused. 

9.  J.  M.  Sixty  years  old.  Male.  For  eight  months 
had  had  an  ulcer  in  the  left  cheek  under  the  eye.  Six  months 
ago  the  upper  jaw  became  involved.  Glands  existed  behind 
the  ramus  of  the  jaw,  and  the  cervical  glands  were  enlarged 


Fig.  26S. — Same  as  Fig.  267.  Xoto  mouth  opened,  exposing  to  view 
characteristic  carcinoma  of  the  lower  alveolar  border.  Cauliflower-like  ap- 
pearance seen. 


in   the   left    side.     Operation   was   refused.     He   died   two 
months  later. 

10.  K.  X.     Forty-two  years  old.     Female.     Large  tumor 
size  of  orange  in  cheek,  involving  nose  and  palate.     Dura- 
tion, four  months.    Lived  eleven  months  after  operation  was 
refused. 

11.  A.    G.     Fifty-three    years    old.     Female.     Swelling 
under  right  eye  involving  inner  canthus,  nose,  and  malar 


270  TUMORS    OF    THE    JAWS 

region;    ulcerated;    palate   and  nose  invaded.     Duration, 
two  months.     Lived  nine  months  after  operation  was  refused. 

The  average  duration  of  life  of  these  cases  of  inoperable 
carcinoma  of  the  jaws  after  being  seen  by  the  surgeon  is 
ten  months. 


Fig.    269.— P.    M.     Man,    sixty  Fig.   270.— P.    M.      Man,   sixty 

years  old.     Tumor,  ten  months  old.      years  old.     (See  Fig.  269.)     Inoper- 
Tumor  involves  the  inside  of  cheek,       able  carcinoma, 
parotid,  and  beginning  to  involve  the 
jaw.     Inoperable  carcinoma. 

CARCINOMA  OF  THE  JAW  OPERATED  ON  AT  THE   CLINIC 

OF  THE  MASSACHUSETTS  GENERAL  HOSPITAL 
Of  the  38  cases  of  carcinoma  of  the  jaws  operated  upon, 
there  were  12  cases  of  the  upper  jaw,  26  cases  of  the  lower 
jaw.     One  case  of  this  group  had  the  disease  in  both  upper 


CARCINOMA   OF   THE   JAWS  271 

/ 

and  lower  jaws,  and  1  of  the  lower  jaw  cases  was  a  case  with 
recurrence. 

Of  these  38  cases  of  carcinoma  of  the  jaws,  4  were  not 
heard  from  after  careful  search.  The  following  is  a  report  of 
these  4  cases: 

1  (No.  23) :  Local  disease  was  removed  from  alveolar 
border  and  cheek.  Epidermoid  carcinoma.  Most  likely 
to  have  recurred.  Operation  in  1896  (upper  jaw). 


Fig.  271. — H.  W.     Carcinoma  of  the  right  lower  jaw. 

2  (No.  34) :   Partial  operation,  excision  of  the  disease. 
Neck  not  dissected.     Had  existed  four  months.     Epidermoid 
carcinoma  (lower  jaw). 

3  (No.  35) :    Complete   left   half   lower   jaw    removed. 
Common    carotid    ligated.     Internal    jugular    removed    to 


272  TUMORS    OF    THE    JAWS 

jugular  foramen.     Neck  dissected.     Epidermoid  carcinoma 
(lower  jaw). 

4  (No.  36) :  Resection  of  one-half  the  lower  jaw.  Dis- 
section of  the  neck.  In  bad  condition.  Probably  recurred 
(lower  jaw). 


Fig.  272. — H.  W.     Carcinoma  of  the  lower  jaw.     Long  duration.     Note  the 
involvement  of  the  lower  jaw,  as  indicated  by  irregular  outline. 


CARCINOMA  OF  THE  LOWER  JAW.     OPERATED  CASES. 

MASSACHUSETTS  GENERAL  HOSPITAL  CLINIC. 

PERCENTAGE  OF  CURES 

Twenty-six  cases  of  carcinoma  of  the  lower  jaw  were 
operated  upon  at  the  Massachusetts  General  Hospital 
clinic:  3  cases  were  not  traced.  There  were  4  deaths  from 


CARCINOMA   OF   THE   JAWS 


273 


operation — a  mortality  of  15  per  cent.  There  are  5  cases 
well  today,  or  19.2  per  cent,  of  all  operated  cases.  If  the 
percentage  of  cures  is  reckoned  out  from  the  traced  cases,  it 
amounts  to  21.7  per  cent.  Twenty-three  cases  were  traced 
and  found  to  have  died  at  varying  intervals  after  operation. 

CARCINOMA  OF  THE  LOWER  JAW.     GASES  DEAD  SOON 
AFTER  THE  OPERATION 

Four  deaths  occurred  because  of  the  operation  for  car- 
cinoma of  the  lower  jaw: 


Fig.  273. — After  removal  of  one- 
half  of  the  lower  jaw  for  carcinoma. 
Patient  lived  five  months  after  opera- 
tion. 


-  '  BP 

Fig.  274. — After  removal  of  one-half 
of  the  lower  jaw  for  carcinoma. 


1.  A  woman,   seventy-one  years  old.     A   complete  re- 
moval of  one-half  of  the  lower  jaw.     Died  of  shock  a  few 
hours  after  operation. 

2.  A  man,  thirty-eight  years  old.     An  alcoholic.     Died 

18 


274  TUMORS   OF   THE   JAWS 

of  shock  after  removal  of  one-half  of  the  lower  jaw  three 
days  following  operation. 

13.  A  man,  fifty-nine  years  old.  Following  an  excision 
of  the  greater  part  of  half  of  the  lower  jaw  and  dissection 
of  the  glands  of  the  neck,  died  of  exhaustion  eight  days  after 
the  operation. 

37.  A  man,  fifty-eight  years  old,  having  a  large  ulcerat- 
ing mass  in  the  midline  of  the  neck  and  attached  to  the  left 
lower  jaw.  Died  after  an  excision  of  one-half  of  the  lower 
jaw  a  few  days  after  operation,  evidently  of  shock  and  ex- 
haustion. 

CERTAIN  CASES  OF  CARCINOMA  OF  THE  LOWER  JAW  DEAD 
FROM  RECURRENCE 

Ten  of  the  23  traced  cases  of  carcinoma  of  the  lower  jaw 
operated  upon  have  died  with  recurrence  of  the  disease. 
The  following  facts  in  this  series  of  cases  are  of  very  great 
interest.  Note  the  duration  of  life  after  operation  in  these 
cases. 

3.  J.  A.  Forty  years  old.  Removal  of  one-half  of 
lower  jaw,  together  with  the  zygoma  and  the  parotid.  The 
external  carotid  was  ligated,  also  the  jugular  vein.  Second 
operation  two  years  following  first,  for  recurrence.  One 
year  and  eight  months  following  the  second  operation  an 
inoperable  recurrence  was  present.  Death  from  carcinoma 
four  years  following  first  operation. 

5.  M.  D.  Sixty-three  years  old.  Duration  of  disease 
previous  to  operation,  sixteen  months.  An  ulcerating  mass 
involving  floor  of  mouth  and  the  lower  jaw.  Removal  of  the 
symphysis  and  the  floor  of  the  mouth.  Death  one  year  and 
five  months  after  operation. 

8.  C.  D.  Twenty-six  years  old.  Six  years  ago  had  an 
ulcer  of  the  lower  lip.  Five  years  ago  the  old-time  V-exci- 
sion  of  the  ulcer  of  the  lip  was  done.  Two  years  later  a 
recurrence  in  the  lower  lip  occurred.  The  whole  lip  was 


CARCINOMA    OF    THE    JAWS 


275 


then  removed.  For  the  past  six  months  there  has  been  a 
recurrence  in  the  lip  and  lower  jaw.  The  present  mouth 
will  admit  only  one  finger.  The  symphysis  was  removed; 
the  disease  was  too  extensive  in  the  floor  of  the  mouth 
for  complete  excision.  The  patient  died  five  months  after 
this  last  operation. 


Fig.  275. — Carcinoma  of  lower  jaw.     Fig.  276. — After    removal     of    carci- 
noma of  lower  jaw. 

11.  J.  M.  Fifty-eight  years  old.  For  four  months 
following  an  abscess  about  a  tooth-root  there  has  been  an 
ulcerating  mass  in  the  mouth,  involving  the  floor  of  the 
mouth  and  the  lower  jaw.  One-half  the  lower  jaw  was  re- 
moved. The  neck  was  not  dissected.  Death  occurred  a 
few  months  after  this  operation. 

13.  D.  W.  R.  Fifty-nine  years  old.  For  five  months 
there  has  been  a  mass  involving  one-half  the  lower  jaw. 


276  TUMORS    OF    THE    JAWS 

Excision  of  one-half  the  lower  jaw  was  done.  The  neck  was 
dissected.  Death  occurred  one  year  following  this  operation. 
14.  P.  D.  Sixty  years  old.  Following  trouble  with  two 
teeth,  an  abscess  and  involvement  of  the  bone  occurred, 
with  what  was  thought  to  be  a  necrosis  of  bone.  One  year 
previous  to  operation  an  incomplete  removal  of  one-half  of 
the  lower  jaw  was  done.  Death  followed  one  year  after 
this  operation. 


Fig.  277. — Carcinoma  of  lower  jaw.  Partial  operation,  excision  of  growth. 
Alive  seven  years  after  operation.  Photograph  taken  seven  years  after  opera- 
tion (Case  No.  10,  Massachusetts  General  Hospital  series,  Richardson). 

15.  J.  R.     Seventy-five  years  old.     Several  years  ago 
had  an  operation  for  necrosis  of  the  jaw.     Evidently  a  part 
of  the  jaw  was  removed.     Some  two  months  previous  to 
operation   a   tumor   appeared   near   the   symphysis.     This 
tumor  was  removed.     Patient  died  seven  months  later. 

16.  J.  T.     Fifty-two  years  old.     A  tumor  of  the  lower 
jaw  extending  to  the  neck  had  existed  for  a  few  months  pre- 


CARCINOMA    OF    THE    JAWS  277 

vious  to  operation.  One-half  of  the  lower  jaw  was  excised. 
Death  followed  three  and  a  half  months  after  operation. 

17.  P.  B.  Fifty-three  years  old.  Two  months  previ- 
ously, after  the  extraction  of  a  tooth  from  the  lower  jaw,  a 
large  swelling  appeared,  extending  into  the  neck.  Many 
enlarged  glands  of  the  neck  were  present.  Removal  of  the 
lower  jaw,  ligation  of  the  common  carotid  and  the  jugular 
vein,  and  thorough  dissection  of  the  neck  done.  Death 
followed  a  few  months  later. 

37.  W.  H.  F.  Fifty-eight  years  old.  A  few  weeks 
previous  to  operation  there  was  an  ulcerating  tumor  within 
the  mouth.  Excised  one-half  of  lower  jaw.  Died  some 
days  after  operation. 

The  recurrence  in  these  cases  has  often  been  a  local  one. 

CARCINOMA  OF  THE  LOWER  JAW  OPERATED  UPON  AT  THE 

MASSACHUSETTS  GENERAL  HOSPITAL   CLINIC. 

CASES  ALIVE  TODAY 

Of  6  cases  of  carcinoma  of  the  lower  jaw  operated  upon, 
all  recovered  from  the  operation,  and  5  of  them  are  alive 
today ;  1  case  lived  five  years  six  months  and  died  of  angina 
pectoris. 

10.  E.G.  Forty-five  years  old.  Three  months  previous 
to  operation  an  ulcer  appeared  in  the  gum  of.  the  lower  jaw 
on  the  left  side.  This  ulcer  presented  indurated  edges. 
The  ulcer,  together  with  the  underlying  bone,  was  removed 
by  M.  H.  Richardson.  The  microscopic  diagnosis  was  an 
epidermoid  cancer.  This  woman  was  alive  and  well  seven 
years  after  the  operation.  (See  Fig.  277.) 

31.  M.  P.  Forty-five  years  old.  For  sixteen  years  this 
woman  has  worn  plates  of  false  teeth.  The  gum  over  the 
lower  jaw  has  been  irritated.  She  has  been  thought  at 
times  to  have  had,  in  connection  with  the  roots  of  carious 
teeth,  caries  of  the  bone.  On  the  right  side  of  the  lower  jaw 


278 


TUMORS    OF    THE    JAWS 


is  a  hard  mass,  which  has  been  present  about  ten  months, 
attached  to  the  jaw  and  extending  below  it.  Inside  the 
mouth  there  is  a  small  ulcer.  Operation;  mass  resected  by 
R.  B.  Greenough.  Glands  in  the  neck  dissected.  Micro- 
scopic examination  proved  this  to  be  an  epidermoid  cancer- 
This  woman  is  alive  and  well  seven  years  after  operation. 

32.  W.  H.  D.  Forty  years  old.  For  four  and  a  half 
months  previous  to  operation  patient  has  had  a  dull  ache  and 
a  soreness  in  the  right  lower  jaw,  resembling  a  grumbling 
toothache.  Two  months  previous  to  operation  an  ulcer  of 


Fig.  278. — Carcinoma  of  right  lower  jaw.  Photograph  taken  four  years 
following  operation  of  removal  of  lower  jaw,  tonsil,  and  glands  of  the  right 
neck  (No.  32,  Massachusetts  General  Hospital  series,  author's  case). 

the  mucous  membrane  appeared  over  the  alveolar  process  of 
the  lower  jaw.  The  glands  in  the  neck  were  enlarged.  For 
a  month  and  a  half  previous  to  operation  he  was  unable  to 
chew  solid  food.  He  has  lost  20  pounds  in  weight  in  four 
months.  Upon  the  right  side  of  the  jaw  there  is  a  mass 
behind  the  molar  teeth,  which  has  ulcerated  into  the 
mouth  and  which  involves  the  soft  palate,  pillars,  and  the 
tonsil.  One-half  of  the  lower  jaw  was  resected,  together 
with  the  tonsil  on  the  right  side,  the  soft  palate,  and  glands 
of  the  neck,  by  C.  L.  Scudder.  Microscopic  examination 


279 

showed  the  growth  to  be  a  squamous-cell  epithelioma.  The 
lymphatic  glands  showed  nothing  unusual.  This  man  was 
alive  and  well  five  years  following  operation.  (See  Fig.  278.) 
38.  W.  H.  F.  Seventy-six  years  old.  Three  months  pre- 
vious to  operation  he  had  his  teeth  pulled.  A  mass  appeared 


Fig.  279. — Complete  resection  of  left  half  of  the  lower  jaw  for  carcinoma. 
No  recurrence  after  five  years.  Photograph  taken  four  years  after  operation 
(No.  38,  Massachusetts  General  Hospital  series,  Conant). 

on  the  left  side  of  the  lower  jaw,  in  the  region  occupied 
by  the  extracted  teeth.  An  operation  of  resection  of  one- 
half  of  the  lower  jaw  was  done  by  W.  M.  Conant.  Microscopic 
examination  showed  an  epithelioma  infiltrating  the  alveolus. 
This  man  is  alive  and  well  today,  over  five  years  and  a 
half  following  operation.  (See  Fig.  279.) 


280  TUMORS    OF   THE    JAWS 

48.  L.  Fifty-nine  years  old.  Six  months  previous  to 
operation  there  existed  an  ulceration  of  the  left  cheek  and 
lower  jaw  into  the  mouth.  Excision  of  one-half  of  the  lower 
jaw,  with  dissection  of  the  neck,  by  C.  L.  Scudder.  Patho- 
logic report  was  a  squamous-cell  carcinoma.  This  man  re- 
turned with  a  persistent  sinus  in  the  scar.  This  sinus  was 


Fig.  280. — Carcinoma  of  lower  jaw  (squamous  cell).  Photograph  taken 
over  two  years  following  the  operation  (No.  48,  Massachusetts  General 
Hospital  series,  author's  case). 

excised  about  a  month  after  the  previous  operation,  and  the 
pathologic  report  was  a  fibroma.  The  wound  broke  down 
a  second  time  and  was  cureted  and  then  closed.  The  wound 
broke  down  a  third  time,  and  the  patient  refused  further 
treatment.  The  patient  is  today  alive  and  well,  two  and  a 
half  years  after  the  first  operation.  (See  Fig.  280.) 


CARCINOMA    OF    THE    JAWS  281 

49.  C.  V.  An  adult.  A  tumor  of-  the  lower  jaw.  At 
operation  a  partial  excision  of  the  jaw  was  done,  without  dis- 
section of  the  neck,  by  M.  H.  Richardson.  Microscopic 
report  was  a  papillary  epidermoid  carcinoma.  This  man 
was  alive  and  well  five  years  and  six  months  after  operation. 
He  then  died  of  angina  pectoris. 

Of  these  recoveries  from  operation,  3  had  had  dissection 
of  the  glands  of  the  neck,  and  3  had  no  glandular  dissection. 

The  Boston  City  Hospital  statistics,  studied  by 
Lothrop  and  Scannell,  are  as  follows  for — 

Carcinoma  of  the  lower  jaw,  a  total  of  13  cases.  .The 
duration  of  the  symptoms  before  consulting  a  surgeon  varied, 
but  averaged  seven  and  a  half  months. 

Two  cases  were  living — one,  five  years  after  operation, 
one  one  and  a  half  years  after  operation. 

There  were  6  complete  excisions.  The  average  duration 
of  life  after  operation  was  sixteen  and  a  half  months. 

There  were  7  partial  excisions.  The  average  duration  of 
life  after  operation  was  seven  months. 

The  operated  cases  lived  four  times  as  long  as  the  non- 
operated  cases.  Those  having  a  complete  excision  lived 
longer  than  those  with  partial  excision. 

There  were  9  cases  of  upper-jaw  excision.  All  had  died. 
Complete  excision,  5  cases.  Partial  excision,  3  cases.  Com- 
plete excision  cases  lived  twelve  months  (average);  the 
partial  excision  cases  lived  five  months  (average).  The 
complete  excision  cases  lived  longest. 

Meller  reports  that  of  8  cases  involving  the  lower  jaw 
and  necessitating  complete  removal  of  one-half  of  the  jaw 
he  found  2  cures,  as  follows : 


282  TUMORS   OF   THE   JAWS 

One  case,  fifty-three  years  old.  The  angle  of  the  jaw 
and  the  submaxillary  glands  were  involved.  The  patient 
was  alive  six  years  and  three  months  subsequently  without 
recurrence.  One  case,  fifty-eight  years  old.  The  disease 
was  about  the  same  in  extent  as  in  the  preceding  case.  One- 
half  the  jaw  was  removed,  and  there  was  made  a  dissection 


Fig.  281. — Carcinoma  of  the  upper  jaw,  man,  thirty-eight  years  old. 
Originated  probably  in  the  antrum.  Note  the  fullness  of  the  cheek  and  the 
displacement  of  the  eyeball  upward;  also  the  deformity  of  the  right  ala  of  the 
nostril  (Morestin). 

of  the  neck.  This  case  was  alive  three  years  and  one  month 
subsequently. 

The  prognosis  of  carcinoma  of  the  jaw  is  far  more  un- 
favorable than  that  of  sarcoma  of  the  jaw. 

Martens  gives  the  average  time  of  recurrence  of  car- 
cinoma of  the  jaw  as  nine  to  ten  months  after  operation. 
Stein,  in  10  cases,  finds  the  average  time  of  recurrence  3.6 
months,  and  death  in  eleven  months.  Behm  records  one 


CARCINOMA   OF   THE   JAWS 


283 


case  which  showed  a  recurrence  eleven  years  after  opera- 
tion. 

Perthes  had  one  case  in  which  he  did  a  partial  resection 
of  the  lower  jaw  for  carcinoma.  Three  years  later  there 
was  a  recurrence.  The  patient  had  nothing  done  for  two 
years,  and  then  five  years  after  the  first  operation  a  complete 
exarticulation  was  done.  This  illustrates  how  late  the 
recurrence  after  operation  may  be.  It  is  hardly  wise  to 
consider  a  case  cured  after  having  had  an  operation  for 
carcinoma.  The  patient  is  to  be  congratulated  so  long  as 
no  recurrence  appears. 

RESECTIONS    OF    THE    UPPER    JAW— STATISTICS    COLLECTED 
FROM    THE    LITERATURE    BY    DR.  EMILIO    COMISSO 


TOTAL  RESECTION.    PARTIAL  RESECTION. 


TOTAL. 


AUTHOR. 

TIME  AND 
CLINIC. 

No. 

DEATHS  PER 

CENT. 

No. 

DEATHS  PER    j\jo      DEATHS  PER 
CENT.                            CENT. 

Rabe  

1827-1873 

277 

74   ' 

152 

18  1                429    92  N 

Hofmokl  .  . 

1852-1870 

Vienna 

43      8 

Ohlemann  . 

1856-1874 

20 

3 

I    25.2 

12 

0    •       1.1      32      3 

Gottingen 

•     20.6 

Kronlein  .  . 

1868-1873       9 

0 

9      0 

Zurich 

Winiwarter 

1868-1875 

10     5  , 

Vienna 

Kiister  .... 

1871-1887 

29 

8 

8 

0 

37      8  ' 

Vienna 

| 

Bayer  

1873-1883 

17 

1 

2 

0 

19,     1 

Prague 

Beckmann  . 

1878-1885       9 

0 

9      0 

Wiirzburg 

•    20.3 

•       5.6 

17.3 

Martens  .  .  . 

1875-1896 

74    23 

12 

] 

86    24 

» 

Gottingen 

Schlatter  .  . 

1881-1900 

35 

1 

35      1 

Zurich 

Schulz  

1887-1897 

18 

4 

16 

1 

34      2 

Greifswald 

Petzold  .  .  . 

1889-1892 

17      2 

Erlangen 

.  Total  .  .  . 

488  114        23.4 

202 

20          9.9    760146         19.6 

CHAPTER  VI 
THE 


CONTENTS  OF  CHAPTER: 

I.  Diagnosis:  Considerations  of  age. — Considerations  of  sex. — Situation  of 
growth. — Consideration  of  duration  and  rate  of  growth. — Considerations 
of  jaw  involved. — Considerations  of  trauma. — Character  of  tumor. 
II.  Principles  underlying  the  treatment  of  malignant  disease  of  the  upper 
jaw:  Operative  treatment:  Preliminary  steps:  Cleansing  the  mouth; 
Stomach-tube;  Morphin. — Anesthetic:  Method  of  administration. — 
Position  of  patient. — Tracheotomy. — Control  of  hemorrhage:  Ligation  of 
the  carotid;  Historic;  Temporary  compression  of  carotid;  Permanent 
ligation  of  carotid;  Pharyngeal  tamponade  and  intubation  of  the  pharynx. 
— Details  of  operation  of  excision  of  upper  jaw:  Removal  of  the  orbital 
plate;  Dissection  of  the  neck. — Principles  of  operative  treatment. — 
Osteoplastic  total  resection  of  the  upper  jaw. — Excision  of  one-half  of 
the  inferior  maxilla. 

DIAGNOSIS 

THE  growths  of  the  jaws  considered  in  the  foregoing 
pages  are  epulis,  sarcoma,  the  fibroma  group  of  tumors, 
pure  odontoma,  carcinoma,  the  adamantine  epithelioma, 
and  the  dentigerous  cyst. 

The  detailed  differentiation  of  these  several  growths  has 
been  carefully  made  in  the  description  of  each  form. 

To  facilitate  the  diagnosis  of  these  tumors  the  surgeon 
should  consider — (a)  The  history  of  the  tumor;  its  exact 
time  of  appearing;  its  precise  location  at  the  beginning;  its 
size  when  first  detected;  the  rate  of  its  growth;  the  jaw  in- 
volved; the  possibility  of  trauma ;  the  condition  of  the  teeth 
in  early  and  adult  life;  associated  conditions  of  pain,  dis- 
comfort, and  deformity;  he  should  consider  the  presence  of 
glandular  enlargement,  metastatic  growth,  cachexia,  syphilis, 

284 


DIAGNOSIS    OF    MALIGNANT    DISEASE  285 

and  tuberculosis.  (6)  The  surgeon  should  make  a  careful 
examination  of  the  tumor,  to  determine  its  physical  charac- 
teristics. If  an  accurate  history  and  a  satisfactory  examina- 
tion of  the  tumor  are  possible,  and  if  the  facts  thus  obtained 
are  interpreted  upon  the  basis  of  the  story  of  individual 
growths  as  related  in  these  pages,  there  should  be  compara- 
tively little  difficulty  in  arriving  at  a  positive  diagnosis. 

Considerations  of  Age. — Sarcoma  of  the  jaw  thrives  before 
fifty  years  of  age.  Between  fifty  and  seventy  years  of  age 
carcinoma  of  the  jaw  flourishes.  The  adamantine  epithelial 
tumor  appears  between  twenty  and  forty  years  of  age. 

Old  age  and  the  age  of  the  milk  teeth  rarely  see  the  ada- 
mantine tumor. 

Considerations  of  Sex. — Men  are  more  likely  than  women 
to  have  carcinoma  of  the  jaw.  Women,  more  often  than 
men,  develop  an  adamantine  epithelial  tumor. 

Considerations  of  the  Initial  Seat  of  the  Growth. — Epulis 
rarely  originates  behind  the  last  molar  tooth.  It  appears 
most  commonly  near  the  canine  and  bicuspid  teeth.  It 
starts  on  the  inner,  rather  than  the  outer,  side  of  the  alveolar 
process.  Epulis  is  almost  never  seated  on  the  body  of  the 
lower  or  upper  jaw. 

Sarcoma  involves  the  body  and  alveolar  process. 

Epithelioma  (carcinoma)  involves  the  jaw  first  along  the 
alveolar  border. 

The  periosteal  osteosarcoma  starts  in  the  body  of  the 
jaw,  near  the  angle,  rather  than  in  the  alveolar  process  or 
ramus. 

Considerations  of  the  Duration  and  Rate  of  Growth. — A 
tumor  of  the  jaw  that  has  existed  for  several  years  was  not 
malignant  at  its  origin,  and  probably  is  not  malignant  at  all. 


286  TUMORS   OF   THE    JAWS 

However,  the  tumor  of  long  life  may  contain  areas  of  malig- 
nant degenerated  tissue.  Especially  is  this  true  if  there  have 
been  periods  of  rapid  growth. 

The  adamantine  tumors,  the  dentigerous  cysts,  the  mixed 
tumors  of  bone,  cartilage,  and  possibly  myxomatous  tissues, 
all  may  have  existed  for  years  before  they  are  brought  to  the 
physician  for  treatment. 

Carcinoma  and  sarcoma  could  not  exist  in  the  jaw  for 
three  years  without  causing  death  or  extreme  local  discom- 
fort, necessitating  surgical  consultation. 

When  a  history  is  obtained  from  a  patient  that  a  jaw 
tumor  has  existed  for  several  years  and  has  been  of  gradual 
gntvvth,  the  tumor  is  probably  benign  in  character. 

A  very  rapidly  growing  tumor  suggests  at  once  a  round- 
cell  sarcoma,  a  perithelial  angiosarcoma,  a  rapidly  filling 
dentigerous  cyst,  an  infected  adamantine  epithelial  growth, 
or  a  carcinoma. 

The  adamantine  tumor  may  be  detected  when  as  small 
as  an  English  walnut ;  it  may  grow  to  the  size  of  a  large  grape- 
fruit. The  adamantine  tumor  is  usually  of  slow  growth. 
It  may  continue  as  many  as  twenty  years  in  duration. 

Carcinoma  of  the  jaw  progresses  rapidly,  without  inter- 
missions. A  patient  with  carcinoma  of  the  jaw  rarely  lives 
longer  than  two  years  after  the  first  appearance  of  the 
disease. 

Considerations  of  the  Jaw  Involved. — The  lower  jaw  is 
more  often  the  seat  of  epulis  than  the  upper  jaw.  The 
lower  jaw  is  more  often  the  seat  of  the  adamantine  epithelial 
tumor  than  the  upper  jaw.  The  adamantine  tumor  is 
seated  on  one  side  of  the  body,  or  on  the  alveolar  border, 
near  the  angle. 


DIAGNOSIS    OF   MALIGNANT   DISEASE  287 

The  upper  jaw  is  the  seat  of  carcinoma  more  frequently 
than  the  lower  jaw.  The  upper  jaw  is  the  seat  of  sarcoma 
more  frequently  than  the  lower  jaw. 

Considerations  of  Trauma. — A  history  of  previous  trauma 
always  should  suggest  that  the  tumor  is  a  sarcoma.  Trauma 
is  probably  not  of  the  same  etiologic  importance  in  carcinoma 
of  the  jaw  that  it  is  in  sarcoma  of  the  jaw. 

Character  of  the  Tumor. — Any  tumor  appearing  in  the 
jaw  after  the  time  of  the  full  development  of  all  the  teeth 
cannot  be  an  odontoma. 

The  adamantine  tumor  grows  most  often  from  the  angle 
of  the  jaw. 

The  kidneys  should  be  palpated  carefully  in  every  case 
of  tumor  of  the  jaw  in  which  there  is  any  good  reason  for 
suspecting  a  metastatic  hypernephroma.  This  is  one  of  the 
unusual  possibilities,  but  is  to  be  kept  in  mind.  The  meta- 
static tumor  may  be  the  evident  growth. 

All  jaw  tumors  should  be  regarded  as  malignant  until 
every  means  has  been  exhausted  to  demonstrate  their  benign 
character. 

A  bony  growth  that  is  situated  upon  the  alveolar  process 
of  the  jaw  (upper  or  lower)  suggests  a  benign  tumor. 

The  periosteal  sarcoma  (ossifying  sarcoma)  does  not 
arise  in  the  alveolar  border— it  arises  from  the  body  of  the 
bone. 

At  the  angle  of  the  lower  jaw,  extending  along  the  ramus, 
grows  the  periosteal  round-  and  spindle-cell  sarcoma.  It 
is  so  malignant  that  it  soon  becomes  incurable  by  operation. 


288  TUMORS   OF   THE   JAWS 

THE  OPERATIVE  TREATMENT  OF  MALIGNANT  TUMORS  OF 

THE  JAW 

Principles  Underlying  the  Treatment  of  Malignant 
Disease  of  the  Upper  Jaw. — The  malignant  forms  of 
sarcoma  and  carcinoma  of  the  jaw  are  rarely  cured  by  opera- 
tion. It  is  the  exception,  rather  than  the  rule,  to  find  cured 
cases  with  well-authenticated  pathologic  reports. 

Very  thorough  removal  of  the  disease  in  its  beginning 
will  eradicate  it. 

In  malignant  disease  of  the  upper  jaw,  whether  carcinoma 
or  sarcoma,  complete  excision  of  the  jaw  is  the  best  plan. 
Partial  operation  upon  the  upper  jaw  for  carcinoma  is  to  be 
employed  only  in  exceptional  cases  of  squamous-cell  car- 
cinoma of  the  alveolar  border. 

The  operative  attack  in  carcinoma  of  the  upper  jaw 
should  have  little  regard  for  anatomic  structure.  If  the 
orbital  tissues  are  involved  directly,  or  if  they  lie  close  to  the 
carcinoma,  the  eye  should  be  removed,  and  the  orbital 
space  cleared  of  its  contents  at  the  primary  operation.  All 
structures  which  prevent  a  thorough  and  complete  removal 
of  the  disease  should  be  sacrificed. 

The  operation  for  removal  of  a  tumor  of  the  upper  jaw 
demands,  on  the  part  of  the  surgeon,  technical  skill  and  an 
appreciation  of  the  details  of  operative  work  second  to  no 
other  operative  procedure. 

Preliminary  Steps. — Cleansing  the  Mouth. — The  buccal 
and  nasal  cavities  are  cleansed  with  difficulty.  Probably 
they  can  never  be  made  absolutely  aseptic.  An  attempt, 
however,  should  be  made  to  render  them  clean.  A  proper 
cleansing  of  the  cavities  of  the  nose  and  mouth  will  con- 
duce to  rapid  healing  of  operative  wounds,  and  will  dimin- 


OPERATIVE    TREATMENT    OF    MALIGNANT    DISEASE       289 

ish  the  liability  to  infection  from  an  ulcer  through  the  cut 
surface. 

A  dentist  should  be  employed  to  remove  or  care  for  all 
carious  teeth.  Any  teeth  remaining  should  be  thoroughly 
scaled  and  burnished.  This  should  be  done  three  or  four 
days  previous  to  operation.  The  tooth-brush  should  be 
used  after  each  feeding,  up  to  the  time  of  operation.  A 
mouth-wash  of  a  mild  alkaline  mixture,  such  as  Dobell's 
solution,  alkalol,  or  Seller's  tablets,  should  be  employed  at 
least  ihree  times  daily  previous  to  operation.  If  it  is  pos- 
sible to  cleanse  the  nose  by  douches  and  sprays,  this  should 
be  done  before  operations  which  are  likely  to  open  the  nasal 
cavity. 

This  attempt  at  cleansing  the  mouth  and  nose  previous 
to  operation  will  diminish  the  number  of  pathogenic  bacteria 
present  in  these  parts.  It  is  a  fact,  moreover,  that  parts 
thus  approximately  cleansed  heal  more  readily  and  kindly 
than  parts  not  thus  cleansed. 

Stomach-tube. — For  several  days  previous  to  a  contem- 
plated operation  the  patient  should  be  taught  to  use  the 
stomach-tube  in  feeding  himself.  He  will  then  become  ac- 
customed to  its  use.  After  operation,  for  at  least  one  week, 
feeding  should  be  accomplished  through  the  stomach-tube. 
The  parts  about  the  jaws  are  thus  afforded  more  com- 
plete rest.  The  likelihood  of  infection  is  lessened,  and  heal- 
ing is  facilitated.  A  mouth-wash  should  be  used  each  time 
after  the  stomach-tube  is  employed. 

Morphin  (|  grain)  and  atropin  (T^-F  grain),  if  given 
hypodermically  one-half  hour  before  operation,  will  make 
the  administration  of  the  anesthetic  (ether)  easier,  and  will 


19 


290  TUMORS    OF   THE   JAWS 

also  render  the  patient's  recovery  from  the  anesthetic  less 
disagreeable. 

Anesthesia. — The  anesthetic  to  be  employed  in  opera- 
tions upon  the  jaws  is  ether.  The  patient  may  first  be  put  to 
sleep  by  ether  administered  from  an  open  cone  over  nose  and 
mouth.  The  continuance  of  the  anesthesia  by  nasopharyngeal 
tubage,  as  suggested  by  Crile,  is  most  satisfactory.  The 
pharynx  is  cocainized.  Two  flexible  rubber  tubes  are  intro- 
duced through  the  nostrils  to  the  pharynx,  just  above  the  epi- 
glottis. The  tongue  is  drawn  forward,  and  a  gauze  tam- 
ponade  placed  in  the  pharynx  snugly  enough  to  retain  its 
position  about  the  tubes  without  compressing  them  unduly. 
These  tubes  are  united  in  a  Y  glass  tube,  which  in  turn  is 
connected  by  rubber  tubing  with  a  glass  tube  containing 
a  bulb  for  catching  the  ether,  which  condenses  and  col- 
lects in  the  apparatus.  This  latter  glass  tube  is  connected 
by  a  rubber  tube  with  a  glass  funnel  containing  gauze  for 
saturation  with  ether. 

By  this  method  of  nasopharyngeal  etherization  the 
anesthetist  is  stationed  away  from  the  field  of  operation. 
The  surgeon  is  not  hampered  by  the  immediate  proximity 
of  the  anesthetist;  the  dangers  from  blood  being  inhaled 
are  removed;  the  operative  procedure  can  be  carried  out 
with  greater  thoroughness,  because  with  less  haste  than  by 
the  older  method ;  the  patient  may  be  operated  upon  in  the 
upright  or  nearly  upright  position,  with  no  trouble  from  blood 
in  the  pharynx.  The  danger  of  postoperative  pneumonia 
is  reduced  to  a  minimum. 

The  Position  of  the  Patient  During  the  Operation.— 
For  forty  years  or  more  the  sitting  or  upright  position  has 
been  employed  for  nearly  all  operations  upon  the  upper  and 


OPERATIVE    TREATMENT    OF    MALIGNANT    DISEASE       291 

lower  jaws  at  the  Massachusetts  General  Hospital,  Boston. 
It  is  the  position  best  suited  to  the  convenience  of  the  sur- 
geon, and  is  satisfactory  for  the  patient.  To  maintain  this 
position  most  effectively  the  head  must  be  held  by  an  or- 
derly during  the  whole  period  of  the  operation  for  the  re- 
moval of  the  upper  or  lower  jaw.  The  head  can  thus  be 
moved  or  turned  at  the  operator's  command.  If  blood 
happens  to  get  into  the  patient's  mouth,  a  tilting  of  the  head 
forward  gives  it  an  opportunity  to  run  out. 

Tracheotomy  will  almost  never  be  required  if  the  above 
methods  are  used.  Tracheotomy  is  in  itself  an  added  risk 
to  the  operative  procedure.  An  emergency  alone  would 
demand  this  operation. 

Assistants. — It  is  necessary  to  have  enough  assistants 
readily  to  do  the  things  required.  There  should  be  a  first 
assistant,  who  shall  assist  in  the  performance  of  the  operation, 
the  handing  of  instruments,  the  tying  of  vessels,  etc.;  a 
second  assistant,  to  retract  and  to  watch  the  mucosa  of  the 
floor  of  the  mouth,  so  as  to  keep  all  blood  from  the  gauze  in 
the  pharynx;  a  third  assistant,  to  administer  the  anesthetic; 
a  fourth  assistant,  the  nurse  who  attends  to  the  sutures  and 
sponges;  a  fifth  assistant,  who  holds  the  head  and  jaw  so 
long  as  it  is  needed. 

Of  course,  this  operation  can  be  done  with  fewer  assis- 
tants, but  there  is  no  operation  which  requires  the  full  com- 
plement of  assistants  more  than  this  one,  if  the  technic  is 
to  run  satisfactorily. 

Control  of  Hemorrhage. — Ligation  of  the  Carotid: 
Historic. — Martens  estimated  the  mortality  following  ex- 
cision of  the  upper  jaw  at  Gottingen  to  be  from  23  to  31  per 
cent,  in  74  cases.  Sixteen  died  from  lung  complications. 


292  TUMORS   OF   THE   JAWS 

From  Greifswaldse  18  resections  of  the  upper  jaw  gave  a 
mortality  of  22  per  cent.  Bryant's  group  of  230  cases  of 
resection  gave  a  mortality  of  14  per  cent. 

These  mortality  rates  were  recognized  as  high.  It  was 
also  understood  that  hemorrhage  at  the  time  of  operation 
into  the  pharynx  and  a  sucking  of  blood  into  the  lung  caused 
many  deaths  from  pneumonia. 

Rose,  in  1878,  advocated  operating  with  the  head  low 
(Rose  position),  so  that  the  blood  accumulating  in  the 
pharynx  might  be  removed  and  an  aspiration  pneumonia 
avoided.  Tracheotomy  and  the  tamponade  cannula  were 
devised  to  prevent  blood  from  entering  the  trachea. 
Methods  of  partial  anesthesia  were  struggled  with,  hoping 
that  the  voluntary  expulsion  of  blood  from  the  pharynx  and 
trachea  might  lessen  the  dreaded  mortality. 

Pirogoff,  in  1840,  and  Madelung,  in  1874,  had  raised  the 
question  of  the  wisdom  of  cutting  off  the  blood-supply  Jto 
the  head  in  operations  upon  the  head,  to  diminish  hemor- 
rhage. 

Schlatter  states  that  Professor  C.  Reyher,  of  St.  Peters- 
burg, first  ligated  the  common  carotid  for  the  checking  of 
hemorrhage  in  some  27  cases  of  head  surgery.  He  had  but 
one  death.  So  fearful  was  Reyher  of  harm  to  the  brain 
from  this  ligation  that  he  was  accustomed  to  practise  inter- 
mittent compression  of  the  vessels  to  be  tied  for  eight  days 
every  hour  for  ten  minutes  previous  to  operation,  to  accustom 
the  brain  to  the  effects  of  the  ligation. 

Zimmerman  found  that  after  ligation  of  the  common 
carotid  there  were  31  per  cent,  of  deaths,  26  per  cent,  of 
these  with  brain  symptoms,  and  11.6  per  cent,  showing 
cerebral  softening.  Riese  found,  in  73  operations  for  ligation 


OPERATIVE    TREATMENT    OF    MALIGNANT    DISEASE       293 

of  the  common  carotid,  17  deaths  and  25  per  cent,  of  cerebral 
disturbance.  Lipps  found  that  of  130  cases  of  ligation  of 
the  external  carotid,  there  were  2  deaths. 

Ligation  of  the  common  carotid  lessened  hemorrhage, 
but  carried  with  it  so  high  a  mortality-rate  in  itself  that  it- 
was  dropped  from  common  surgical  practice.  Ligation  of 
the  external  carotid  avoided  the  cerebral  complications  at- 
tending ligation  of  the  common  carotid,  but  introduced  a 
new  danger — cerebral  embolism.  It  was .  found  that,  by 
placing  the  ligature  upon  the  external  carotid  too  near  the 
bifurcation  of  the  common  carotid,  a  thrombus  forming  in 
the  external  carotid  extended  into  the  internal  carotid,  and 
in  a  number  of  cases  a  portion  of  this  thrombus  became  de- 
tached and  a  cerebral  embolism  resulted. 

Von  Lesser,  in  1882,  temporarily  ligated  the  common 
carotid  in  man  successfully.  Eberth  and  Schimmelbusch, 
in  1888,  studied  the  effect  in  animal  vessels  of  temporary 
compression.  Senger,  in  1895,  demonstrated  that  the  ar- 
teries of  animals  could  be  compressed  temporarily  without 
harm  to  the  artery.  He  successfully  temporarily  compressed 
the  external  carotid  upon  man.  Schoenborn,  from  the 
Konigsberg  clinic  in  1896,  used  a  temporary  clamp  for  the 
carotid,  and  exhibited  at  the  International  Surgical  Congress 
at  Rome  a  clamp  for  this  purpose. 

Crile,  in  this  country  (1902),  recorded  his  experiments 
upon  dogs  and  man  of  temporary  compression  of  the  carotid. 
He  published  the  details  of  28  compressions,  with  the  results. 
CVile's  cases  were  operated  upon  between  the  years  1897  and 

1901. 

It  will  thus  be  seen,  from  this  hasty  outline,  that  today 
we  have  arrived  at  temporary  compression  of  the  large 


294  TUMORS    OF   THE    JAWS 

vessels  of  the  neck  instead  of  ligation  for  operations  upon  the 
head,  neck,  and  jaws.  Temporary  compression  is  safe  and 
efficient.  Ligation  may  be  dangerous. 

Temporary  compression  of  the  external  carotid  is  usually 
efficacious  in  preventing  undue  bleeding  in  operations  upon 
the  jaws.  Temporary  compression  of  the  common  carotid 
may  at  times  be  advantageously  employed  in  very  large 
growths. 

Permanent  ligation  of  the  common  carotid  had  best  not  be 
done,  because  of  the  high  mortality  attending  it,  especially 
in  those  past  fifty  years — the  age  when  these  operations  are 
likely  to  be  needed. 

Permanent  ligation  of  the  external  carotid,  if  the  ligature  is 
placed  well  above  the  origin  of  the  vessel,  is  comparatively 
safe. 

Matas,  in  a  large  series  of  some  100  ligations  of  the  ex- 
ternal carotid,  has  had  but  2  fatalities.  These  two  fatalities 
were  among  the  earlier  cases  done  by  him,  when  the  ligature 
was  placed  low  (personal  communication). 

If  the  ligature  is  placed  above  the  superior  thyroid  and 
all  branches  of  the  external  carotid  are  ligated  separately, 
then  there  is  no  risk. 

Temporary  compression  of  the  common  carotid  is  per- 
fectly safe  and  effective,  and  is  the  procedure  of  choice. 
Temporary  compression  of  the  external  carotid  is  usually 
efficient. 

In  atypical  operations  and  partial  resections  ligation, 
permanent  or  temporary,  is  unnecessary. 

The  choice  of  the  place  of  compression  of  the  common  or 
external  carotid  is  similar  to  the  place  for  ligation — some 
little  distance  from  the  bifurcation. 


OPERATIVE    TREATMENT    OF    MALIGNANT    DISEASE       295 

One  should  always  avoid  unnecessary  trauma  to  the 
artery  itself.  In  ligation  the  walls  of  the  vessel  are  to  be 
firmly  approximated,  not  crushed.  Unless  the  compression 
of  the  vessel  is  carefully  graduated,  undue  pressure  upon  the 
intima  may  damage  it,  thus  causing  a  thrombus,  from  which 
later  may  go  an  embolus. 

The  Pharyngeal  Tamponade  and  Intubation  of  the  Pharynx. 
—Packing  the  pharynx  was  first  suggested  by  Gosselin  in 
1855,  for  preventing  blood  from  getting  into  the  trachea. 
It  was  later  practised  by  Verneuil.  In  1869  it  was  employed 
by  Nussbaum,  together  with  a  previous  tracheotomy.  In 
1870  came  Bellocq's  balloon,  Trendelenburg's  tampon  can- 
nula,  and  Rosenbach's  modification  of  the  latter.  A  little 
later  Rabe  used  a  catheter  in  the  glottis.  Rose  used  his 
position  that  gravity  might  turn  the  flow  of  blood. 

Today  the  administering  of  ether  by  the  nasopharyngeal 
tube  (Crile),  which  is  surrounded  by  gauze  in  the  pharynx, 
prevents  what  little  blood  may  appear  from  getting  further 
than  the  gauze  pack.  The  employment  of  direct  tubage  to 
the  larynx  and  trachea  has  no  advantage  in  these  cases. 

The  Operation  of  Excision  of  the  Upper  Jaw. — The 
patient  for  excision  of  the  upper  jaw,  having  been  anes- 
thetized and  thoroughly  relaxed,  is  placed  in  an  upright 
sitting  and  partly  reclining  position.  The  chest  and  shoul- 
ders are  carefully  protected  by  warm  coverings.  The  head  is 
held  upright  by  an  orderly,  who  stands  behind  the  patient's 
chair,  holding  the  head  in  a  firm  grasp  of  both  hands  upon 
the  sides.  The  head  is  thus  held  firmly  at  any  angle  desired 
by  the  operator — it  is  an  intelligent  hold. 

A  gag  is  placed  in  the  mouth.  The  nasal  tubes  of  Crile 
are  introduced,  and  are  seen  to  rest  at  the  level  of  the  back 


296  TUMORS    OF    THE    JAWS 

of  the  epiglottis.     The  tongue  is  drawn  forward  by  a  thread 
passed  through  its  center  and  caught  in  a  snap. 

At  the  time  of  the  operation  any  bleeding  ulcers  or  dirty 
ulcerations  within  the  mouth  should  be  burned  with  the 
actual  cautery,  to  disinfect  and  dry  the  parts. 


Fig.  282. — Showing  the  most  satisfactory  incision  (Ferguson- Webber)  to  he- 
used  in  excision,  of  the  upper  jaw. 

The  pharynx  is  filled  with  sterile  gauze  packed  fairly 
snugly  around  the  rubber  nasal  tubes,  so  that  little  or  no  air 
enters  excepting  through  the  nasal  tubes.  Nasal  breathing 


PLATE  VI 


Showing  the  superficial  flap  reflected  so  as  to  expose  the  origin  of  the 
masseter;  the  loop  through  the  tongue;  the  orbital  contents  retracted  gently; 
the  incisor  tooth  extracted;  the  nasal  cavity  opened.  Note  the  gag  in  situ; 
the  muscular  attachments  still  adherent  to  the  upper  jaw;  the  infra-orbital 
foramen  and  its  contents. 


OPERATIVE    TREATMENT    OF    MALIGNANT    DISEASE       297 

is  favored,  and  pharyngeal  soiling  with  blood  is  avoided, 
by  the  gauze  tampon. 

The  incision,  according  to  Dieffenbach  or  Ferguson,  is 
made  from  the  outer  canthus  of  the  eye  to  the  inner  canthus, 
down  along  the  nose  and  cheek,  in  the  lateral  sulcus  curving 
around  the  ala  of  the  nose,  to  the  median  line  of  the  upper  lip 


Fig.  283. — Showing  (somewhat  diagrammatically)  the  mouth  wide  open, 
incisor  tooth  extracted.  Note  the  incision  in  the  median  line  and  at  the 
junction  of  the  hard  and  soft  palates  in  the  roof  of  the  mouth. 

and  through  the  upper  lip.  This  mucocutaneous  flap  is  re- 
flected back  off  the  bone  far  enough  to  bring  into  view  the 
anterior  portion  of  the  malar  bone  origin  of  the  masseter 
muscle  (Plate  VI).  The  incisor  tooth  is  extracted  upon  the 
side  from  which  the  bone  is  to  be  removed.  There  remain 
to  be  divided  the  bony  attachments  of  the  upper  jaw.  The 
hard  palate  is  divided  by  a  narrow-bladed  saw  introduced 


298  TUMORS    OF   THE   JAWS 

into  the  nostril  of  the  side  to  be  removed.  Before  completing 
the  saw  cut  the  soft  palate  should  be  freed  from  the  hard 
palate,  and  a  median  incision  made  with  a  knife  down  to 
bone  along  the  hard  palate. 

The  nasal  process  of  the  superior  maxilla  is  divided  by  a 
small,  sharp-pointed  bone-forceps.  The  malar  attachment 
is  best  partially  divided  by  a  narrow-bladed  saw,  and  the 
division  completed  by  the  bone-forceps. 

The  pterygomaxillary  attachment  is  now  to  be  divided. 
A  chisel  is  entered  between  the  posterior  edge  of  the  superior 
maxillary  alveolar  process,  just  in  front  of  the  pterygoid 
plate.  A  sharp  blow  of  the  hammer  upon  the  chisel  thus 
placed  severs  this  attachment.  The  orbital  plate,  if  it  is  to 
be  left  in  situ,  is  divided  from  the  infra-orbital  ridge  by 
chisel  or  sharp,  strong  scissors  or  bone-forceps.  If  it  is  not 
to  be  retained,  it  is  then  removed  with  the  entire  bone 
intact. 

The  upper  jaw  is  now  grasped  by  lion  forceps,  holding 
the  infra-orbital  ridge  and  anterior  alveolar  border,  and 
twisted  out  of  place.  Any  remaining  shreds  of  tissue  hold- 
ing the  bone  and  tumor  are  divided  by  scissors. 

Into  the  cavity  left  by  the  jaw  and  tumor  is  immediately 
thrust  a  large  temporary  gauze  packing.  This  will  probably 
check  all  bleeding.  If,  by  chance,  visible  bleeding  vessels 
are  found  after  the  pack  has  remained  in  situ  a  few  moments, 
these  are  twisted  or  ligated. 

The  relatively  superficial  parts,  the  jaw  and  tumor,  which 
have  obstructed  a  view  of  the  deeper  important  structures, 
having  been  removed,  there  follows,  perhaps,  the  most  im- 
portant part  of  the  operation — the  minute  inspection  of  all 
parts  suspected  of  malignant  disease.  Keen  has  emphasized 


OPERATIVE    TREATMENT    OF    MALIGNANT   DISEASE       299 

the  importance  of  observing  very  great  care  in  clearing  out 
all  sinuses  which  may  contain  malignant  disease.  Those 
sinuses  communicating  with  the  nose  directly  should  be 
carefully  inspected.  The  posteriorly  and  anteriorly  seated 
ethmoid,  sphenoid,  and  frontal  cells  all  require  inspection. 


Fig.  284. — Showing  the  appearances  after  the  removal  of  the  upper  jaw. 
Note  the  division  of  bony  surfaces— the  malar,  the  hard  palate,  the  pterygoid 
plate.  Note  the  soft  palate  intact. 

It  is  into  these  remote  recesses  that  malignant  disease 
may  grow,  and  they  should  be  explored  most  assiduously 
if  a  recurrence  of  the  disease  is  to  be  avoided.  (See  figures 
illustrating  the  sinus  relations.) 

The  temporary  packing  having  been  replaced  by  a  per- 


300 


TUMORS   OF   THE   JAWS 


manent  iodoform  packing,  the  external  wound  is  closed. 
The  edges  of  the  skin  should  be  very  carefully  approximated. 


Fig.  285. — A  diagrammatic  drawing  showing  two  commonly  employed 
lines  of  incision — the  upper  one  for  excision  of  the  upper  jaw,  the  lower  one 
for  excision  of  one-half  the  lower  jaw;  the  middle  incision,  from  the  angle  of 
the  mouth,  is  occasionally  employed  in  operations  upon  the  lower  jaw.  Note 
the  relations  of  the  seventh  nerve  to  the  lines  of  incision  (after  Bockenheimer ) . 

The  patient  is  put  to  bed,  lying  down  at  first.  Subse- 
quently he  is  allowed  to  assume  a  semi-sitting  posture.  The 
patient  is  permitted  to  be  up  and  about  two  days  following 


OPERATIVE    TREATMENT    OF    MALIGNANT    DISEASE       301 

the  operation.  The  immediate  shock  from  the  operation 
is  sometimes  considerable,  but  ordinarily  is  not  very  marked. 

Following  the  healing  of  the  wound,  there  need  be  very 
slight  visible  cicatrix. 

If  the  carotid,  either  external  or  common,  has  been  tem- 
porarily compressed,  it  is  wise  to  remove  the  compression 
before  the  final  tamponade  of  the  cavity  is  made,  and  before 
the  skin  sutures  are  placed,  in  order  to  be  positive  that  no 
vessel  still  requires  ligation.  If  ligation  of  either  carotid 
has  been  done,  the  final  tamponade  should  be  just  as  rigor- 
ously placed  as  if  no  ligation  existed. 

Removal  of  the  orbital  plate  of  the  upper  jaw  may  result 
in  such  discomfort  to  the  individual  from  diplopia,  etc.,  that 
it  is  to  be  seriously  considered  before  being  attempted.  If 
the  disease  cannot  be  removed  thoroughly,  i.  e.,  if  the  growth 
has  invaded  the  orbital  cavity  or  encroaches  upon  it  at  all, 
it  is  wise  to  remove  the  orbital  plate.  If  the  cavity  of  the 
orbit  is  involved  in  the  disease,— I  speak  now  of  carcinoma 
especially, — then  the  eye  and  all  the  contents  of  the  orbital 
space  must  be  removed  thoroughly.  This  is  especially  true 
of  carcinoma  starting  in  the  superficial  parts  of  the  face. 
The  moment  it  is  detected  extending  to  the  parts  of  the  orbit, 
no  matter  how  superficially  at  first,  then  the  whole  of  the 
orbital  contents  must  be  removed  if  safety  is  desired. 

The  orbital  plate  support  may  be  provided  by  using,  as 
suggested  by  Konig,  a  bit  from  the  coronoid  process  of  the 
inferior  maxilla  and  its  attached  temporal  muscle-fibers. 
Such  a  bone-flap,  swung  across  under  the  eye,  affords  satis- 
factory support  to  the  globe  of  the  eye. 

Dissection  of  the  Neck. — In  cases  of  sarcoma,  unless  the 
glands  are  palpable,  dissection  of  the  neck  is  probably 


302  TUMORS    OF   THE    JAWS 

unnecessary.  In  cases  of  carcinoma  of  the  upper  jaw  the 
neck  should  be  dissected,  and  upon  both  sides,  from  the 
clavicle  up  to  the  base  of  the  skull.  Despite  the  fact  that 
certain  cases  seemingly  recover  and  live  many  years  with- 
out a  dissection  of  the  neck,  the  operative  attack  in  ordi- 
nary cases  cannot  be  too  vigorous. 

All  parts  should  be  sacrificed  that  in  any  way  may  pre- 
vent a  thorough  and  complete  removal  of  the  disease. 

Principles  of  Operative  Treatment. — Operations' for  the 
removal  of  malignant  tumors  of  the  upper  jaw  may  be  per- 
formed in  two  stages.  It  may  be  wise,  under  certain  cir- 
cumstances, to  operate  upon  the  jaw  at  one  time,  and  upon 
the  cervical  glandular  enlargements  at  another.  The  gland- 
ular dissection  should  precede  the  operation  upon  the  jaw. 
The  dissection  of  the  neck  should  be  most  thorough. 

Those  cases  without  definite  glandular  enlargement  are 
the  ones  in  which  it  is  best  completely  to  dissect  the  neck. 
This  dissection  of  the  neck  should  be  done  at  the  primary 
operation,  reserving  for  a  second  operation  the  removal  of 
the  jaw  tumor. 

The  interval  between  the  two  operations  should  be  short 
— at  least  two  weeks.  It  is  possible  to  recover  well  from  a 
neck  dissection  within  that  time,  whereas  recovery  from  a 
jaw  resection  is  attended  with  discomfort  over  a  longer 
period  of  time.  Therefore  it  seems  wise  to  attack  the  jaw 
tumor  after  the  neck  dissection.  In  a  few  cases  it  may  be 
perfectly  feasible  to  do  both  operations  at  one  sitting. 

Prolonged  shock,  secondary  hemorrhage,  infection  of  the 
operative  field,  pneumonia,  and  meningitis  following  opera- 
tion for  the  removal  of  the  upper  jaw  are  all  practically 
eliminated  today. 


OPERATIVE    TREATMENT    OF    MALIGNANT    DISEASE       303 

Osteoplastic  Total  Resection  of  the  Upper  Jaw.~ 

Osteoplastic  total  resection  of  the  upper  jaw  for  growths 
lying  posteriorly  in  the  nasopharynx  is  the  operation  of 
Kocher.  By  it  the  jaw  is  turned  to  one  side  and  afterward 


Fig.  286. — The  incision  through  skin,  superficial  fascia,  and  platysma 
for  operation  of  excision  of  one-half  of  the  lower  jaw.  Note  nasopharyngeal 
tubage  for  administration  of  anesthetic. 


brought  back  into  its  normal  relations.  The  steps  of  the 
procedure  are  similar,  with  modifications,  to  those  for  re- 
moval of  the  jaw.  There  are  the  same  primary  incision, 
without  separation  of  the  soft  parts  from  the  bone,  a  division 
of  all  the  bony  attachments  of  the  upper  jaw,  and  a  division 


304 


TUMORS   OF   THE   JAWS 


of  the  malar  process  through  a  small  skin  incision.  The 
superior  maxilla,  together  with  the  attached  skin,  can  then 
be  reflected,  and  the  nasopharynx,  with  its  contained  tumor, 
thoroughly  exposed. 

There  have  been  14  cases  recorded  in  which  such  an 
osteoplastic  resection  of  the  upper  jaw  has  been  done.     The 


Fig.  287. — Upper  flap  drawn  upward.     Deep  fascia  incised.     Submaxillary 
gland  exposed  and  drawn  upward. 


operation  is  attended  with  very  little  hemorrhage,  which 
may  at  all  times  be  controlled  by  gauze  packing,  the  tam- 
ponade  being  very  efficacious. 

Ligation  of  the  external  carotid  or  temporary  compression 
of  the  carotid  has  not  been  thought  necessary. 

Kocher,    Depaye,    Enderlen,    Payr,    Streissler,    Garre, 


OPERATIVE    TREATMENT   OF   MALIGNANT   DISEASE       305 

Hertle,  Hoffmann,  and  von  Bergmann  record  such  cases  of 
osteoplastic  operation. 

In  these  cases  of  osteoplastic  resection  of  the  superior 
maxilla  the  oral  intubation  suggested  by  Kuhn  has  distinct 
value. 


Fig.  288. — Lower  border  of  inferior  maxilla  cleared.     Digastric  muscle  seen. 
Facial  artery  and  vein  divided  between  ligatures. 


Streissler's  patient  (sarcoma)  died  of  recurrence  in  loco 
several  months  later. 

Hertle's  patient  was  operated  on  (fibroma)  again  after 
three  years  for  recurrence,  with  good  results  functionally 
and  cosmetically. 

Excision  of  One-half  of  the  Inferior  Maxilla. — Even 
though  the  old-time  stated  operations  for  malignant  disease 
20 


306 


TUMORS   OF   THE   JAWS 


are  less  frequently  done  today,  yet  there  is  an  accuracy  at- 
tained by  following  the  conventional  description. 

The  patient  is  most  conveniently  operated  upon  in  the 


Fig.  289. — Submaxillary  gland  and  attached  planes  of  cellular  tissue  bear- 
ing lymphatic  glands  removed.  Upper  flap  drawn  upward.  Mouth  not  yet 
opened  along  alveolar  attachment  of  buccal  mucosa.  Masseter  muscle  divided. 
Hypoglossal  nerve  seen  lying  on  hyoglossus  muscle. 


semi-recumbent  position,  with  the  head  turned  slightly  to 
the  side  opposite  to  the  disease.  A  thread  of  silk  or  silk- 
worm gut  is  passed  through  the  tongue  an  inch  from  the  tip, 


OPERATIVE    TREATMENT    OF    MALIGNANT    DISEASE       307 

in  the  median  line.  This  serves  to  control  the  position  of 
the  tongue  at  different  periods  of  the  operation,  at  the  same 
time  causing  the  minimum  amount  of  trauma. 

The  placing  of  nasopharyngeal  tubes,  facilitating  the 
administration  of  the  anesthetic,  and  the  packing  of  the 


Fig.    290. — Central   incisor   tooth   extracted.     Sawing   through   the   inferior 

maxilla. 


pharynx  with  gauze,  having  been  completed,  ether  is  given 
with  convenience  and  efficiency,  and  blood  is  hindered  from 
trickling  into  the  larynx  by  the  pharyngeal  gauze  tampon. 
Rarely  will  any  control  of  the  circulation,  such  as  compres- 
sion or  ligation  of  the  carotid,  be  required. 


308 


TUMORS    OF    THE    JAWS 


The  incision  (see  Fig.  286)  beginning  at  the  middle  of  the 
lower  lip,  extends  in  a  downward  curve  to  the  level  of  the 
upper  border  of  the  thyroid  cartilage,  and  from  here  upward 


Fig.   291. — Inferior  maxilla   divided.     Alveolar   mucosa   attachment    being 

divided. 

and  still  backward  to  a  point  in  front  of  and  below  the 
lobe  of  the  ear. 

The  incision  includes  the  skin,  subcutaneous  tissue,  and 
platysma  muscle.  The  platysma  is  reflected  with  the  skin 
in  order  that,  by  subsequently  suturing  the  platysma,  the 
skin  may  be  more  accurately  approximated,  and  there  may 


OPERATIVE    TREATMENT    OF    MALIGNANT    DISEASE       309 

be  less  subsequent  traction  upon  the  superficial  scar  by  the 
deep  cicatrix. 

The  reflection  of  this  flap  exposes  the  outer  surface  of  the 


Fig.  292. — Inferior  maxilla  grasped  by  lion  forceps,  everted  and  depressed. 

jaw  and  submaxillary  region.  The  mucous  membrane  just 
to  the  outer  side  of  the  alveolar  process  is  not  yet  divided. 
The  mouth  cavity  is  unopened  throughout  the  great  extent 
of  the  wound.  (See  Fig.  289.) 


310 


TUMORS   OF   THE   JAWS 


This  incision  avoids  important  facial  nerve  branches  and 
affords  convenient  access  to  the  whole  submaxillary  region. 


Fig.  293. — Inferior  maxilla  everted,  rotated  outward,  and  depressed,  to 
expose  the  temporomaxillary  joint.  Capsule  of  joint  incised.  Temporal 
muscle  coronoid  attachment  divided.  External  maxillary  artery  is  seen  near 
the  border  of  the  external  pterygoid  muscle. 

The  facial  artery  is  immediately  secured  between  two 
ligatures  where  it  enters  beneath  the  submaxillary  gland. 


OPERATIVE    TREATMENT    OF    MALIGNANT   DISEASE       311 

The  fascia  covering  the  gland  anteriorly  is  divided,  the  floor 
of  the  submaxillary  triangle  is  uncovered,  and  its  contents 
are  carried  upward  with  the  gland. 

The  edge  of  the  bony  jaw  is  uncovered  for  its  whole  length. 
All  the  fascial  and  cellular  tissue  is  detached  from  the 
jaw  and  turned  down  with  the  submaxillary  gland  and  the 
submaxillary  triangle  contents. 

The  planes  of  cellular  tissue  carrying  the  lymphatics  are 
followed  as  planes  beneath  the  muscles  of  the  floor  of  the 
mouth  anteriorly.  The  submaxillary  gland,  lymphatics, 
and  cellular  planes  of  lymph  tissue  are  removed  en  masse. 

The  jaw  is  freed  of  all  attached  tissue  by  blunt  dissection 
upon  the  inner  side  as  far  as  the  mucous  membrane  of  the 
floor  of  the  mouth.  The  muscles  anteriorly,  the  digastric, 
mylohyoid,  and  the  geniohyoid,  are  divided  or  separated 
from  the  maxilla  at  their  origins. 

An  incisor  tooth  is  extracted.  The  jaw  is  divided  by  a 
saw  from  before  backward.  (See  Fig.  290.)  Before  wholly 
dividing  the  bone  by  the  saw,  the  bone  forceps  is  used  to  com- 
plete the  section.  The  attachment  of  the  j  aw  to  the  mucosa  is 
divided  within  and  without  the  alveolar  border;  these  two 
lines  of  section  meet  posteriorly  beyond  the  last  molar  tooth. 
The  jaw  is  held  anteriorly  by  bone  forceps  for  greater  ease 
of  manipulation.  (See  Fig.  292.) 

Upon  retraction  of  the  flap  near  the  angle  of  the  jaw,  and 
upon  adducting  the  half  of  the  jaw,  the  masseter  muscle  is 
divided;  after  abducting  the  jaw  the  internal  pterygoid  is 
divided;  after  depressing  the  jaw  the  attachment  of  the 
temporal  muscle  is  divided — -the  greater  part  of  this  attach- 
ment is  to  the  inner  side  of  the  coronoid  process;  upon  still 
further  depressing  the  jaw  the  external  pterygoid  is  divided, 


312  TUMORS   OF   THE   JAWS 

and  the  capsule  of  the  joint  is  opened  above  the  deep  internal 
maxillary  artery.  (See  Fig.  293.) 

Great  care  must  be  used  to  avoid  wounding  the  internal 
maxillary  artery.  It  lies  close  to  the  neck  of  the  condyloid 
process  posteriorly  and  below  the  capsule. 

The  external  lateral,  the  internal  lateral,  and  the  stylo- 
maxillary  ligaments  are  divided  necessarily  together  with  the 
division  of  the  capsule  of  the  joint  and  the  external  ptery- 
goid  muscle.  The  jaw  is  removed  by  a  slight  rotatory  move- 
ment. 

A  careful  search  for  enlarged  glands  is  now  made  along 
the  deep  vessels  in  the  lower  part  of  the  wound.  If  it  is 
thought  necessary,  the  neck  may  be  cleared  of  the  cervical 
lymphatics  through  an  incision  parallel  with  the  sterno- 
mastoid. 

The  floor  of  the  mouth  may  be  carefully  inspected  and 
all  suspected  tissue  removed. 

Complete  hemostasis  is  secured.  The  mucosa  is  su- 
tured. Great  care  should  be  exercised  in  securing  as  tight 
closure  of  the  oral  cavity  as  possible.  Infection  of  the  neck 
is  thereby  prevented.  The  platysma  muscle  is  sutured. 
The  skin  is  sutured.  Drains  of  rubber  tissue  are  placed 
at  the  dependent  parts  of  the  neck  wound.  Concerning 
the  employment  of  prosthetic  apparatus  see  Chapter  IX. 


ANATOMY    OF    SINUSES   OF   THE    NOSE 


313 


ANATOMY  OF  THE  SINUSES   OF  THE  NOSE  AND   THEIR  RELA- 
TION TO  THE  UPPER  JA.W 

The  very  great  importance  of  an  intimate  knowledge 
of  these  sinuses  of  the  deep  head  and  face,  in  connection 
with  malignant  disease  of  the  upper  jaw,  prompted  me  to 
introduce  the  following  illustrations  of  the  anatomy  of  the 
regions  in  question. 


Fig.  294. — Note  probe  passing  from  superior  meatus  of  nose  into  the 
sphenoid  sinus,  sf,  Frontal  sinus;  ss,  sphenoid  sinus;  p,  hard  palate;  E, 
Eustachian  tube.  That  malignant  disease  may  readily  extend  is  apparent 
(after  Onodi).  cs,  Superior  turbinate;  mns,  superior  meatus;  cm,  middle 
turbinate;  mnm,  middle  meatus;  ci,  inferior  turbinate;  mni,  inferior  meatus. 

I  believe  that  early  and  radical  inspection  of  the  sinuses 
by  the  surgeon  at  operation  upon  these  parts,  and  more 
thorough  removal  of  suspected  tissue  from  the  sinuses,  will 
help  to  diminish  the  frequency  of  local  recurrence  fol- 
lowing operation  for  malignant  disease  of  the  upper  jaw. 


Fig.  295. — Note  the  frontal  sinuses  and  cells  and  the  nasolacrimal  duct  (from 

Killian). 


Fig.  296. — Note  the  ethmoid  cells,  the  sphenoid  sinuses,  the  frontal 
sinuses,  and  the  superior  longitudinal  sinus.  The  base  of  the  anterior  fossa 
has  been  removed  to  expose  the  relative  position  of  those  structures.  The  close 
relation  of  the  upper  nasal  sinuses  to  the  meninges  is  evident  (from  Killian). 

314 


*/ 


cep 


Fig.  297. — Note  the  passage  connecting  the  bulla  frontalis  with  the  middle 
meatus  of  the  nose,  sf,  Frontal  sinus;  bf,  bulla  frontalis;  d,  passage;  cm, 
middle  turbinate;  mnm,  middle  meatus;  ci,  inferior  turbinate;  ss,  sphenoid 
sinus;  cea,  ethmoid  cells.  A  new-growth  may  extend  along  this  passage  from 
the  nose  (after  Onodi). 


Fig.  298.  —  Note  the  close  proximity  of  the  cerebral  cavity  to  the  frontal 
sinuses  and  ethmoid  cells,  sfs,  Right  frontal  sinus;  sfd,  left  frontal  sinus; 
bfs,  right  bulla  frontalis;  ce,  ce,  ce,  ce,  ce,  ethmoid  cells;  s,  septum;  bfd,  left 
bulla  frontalis  (after  Onodi). 

315 


Fig.  299. — Note  relations  of  frontal  sinus  to  anterior  cranial  fossa.  Note 
the  thin  bony  wall  separating  the  orbit  from  the  nasal  fossae,  and  separating 
the  cranial  cavity  from  the  superior  nasal  fossa  at  d.  o,  Orbit;  sf,  frontal 
sinus;  s,  nasal  septum;  p,  palate;  sm,  antrum  (from  Onodi). 


Fig.  300. — Note  the  relation  of  the  ethmoid  cells  to  the  sphenoid  sinuses. 
no,  Optic  nerve;  ceps,  ethmoid  cells;  sss,  sphenoid  sinus;  ssd,  ethmoid  cells; 
sm,  antrum;  mnm,  middle  meatus  of  nose;  p,  hard  palate;  s,  nasal  septum; 
cs,  superior  turbinate;  cm,  middle  turbinate;  ci,  inferior  turbinate  (from 
Onodi). 

316 


Fig.  301. — Note  the  depth  from  the  skin  surface  to  which  search  for  dis- 
ease in  sphenoid  sinus  leads  one.  Note  delicate  walls  of  sinuses,  ss,  Sphenoid 
sinus;  ci,  internal  carotid;  sin,  antrum;  s,  septum  (after  Onodi). 


Fig.  302. — Note  the  intimate  relation  between  the  frontal  sinus  and  the 
nasal  sinuses:  disease  in  one  may  extend  easily  to  the  other,  c,  Cerebrum; 
/,  falx  cerebri;  sf,  frontal  sinus;  o,  orbital  contents;  p,  mouth  cavity; 
sm,  antrum;  cm,  middle  turbinate;  mnm,  middle  meatus;  ci,  inferior  turbinate; 
s,  septum;  mni,  inferior  meatus;  sm,  antrum  (after  Onodi). 

317 


cep    cep       os     s       os 


Fig.  303. — Note  the  opening  os  into  the  sphenoid  cells  from  the  superior 
meatus.  Note  angular  wall  of  sphenoid  cells,  pn,  pn,  Superior  meatus; 
s,  septum;  cep,  ethmoid  cells;  os,  entrance  to  sphenoid  cells;  sm,  antrum; 
p,  hard  palate;  ci,  inferior  turbinate;  cm,  middle  turbinate;  cs,  superior 
turbinate  (after  Onodi). 


"X 


Fig.  304. — Showing  the  anterior  view  of  the  neck,  the  symphysis  of  the 
jaw  divided,  tongue  erect.  Note  the  position  of  the  glands  upon  the  deep 
vessels  high  up,  where  the  digastric  crosses.  These  deep  glands  are  the 
important  ones  to  be  removed  in  operations  for  malignant  disease  of  the  jaws. 
Note  the  lettered  groups  of  lymphatics  a,  b,  d,  f,  etc.  (from  Kuttner). 

318 


CHAPTER  VII 
TUMORS  OF  THE  PALATE 

CONTENTS  OF  CHAPTER:  Papilloma  of  the  palate. — Dermoid  tumors  of  the 
palate. — Sarcoma  of  the  palate. — Melanotic  sarcoma  of  the  palate. — Car- 
cinoma of  the  palate  and  uvula,  operation  for. — Mixed  tumors  of  the 
palate. — Seventeen  cases  of  palate  tumors  at  the  Massachusetts  General 
Hospital  clinic,  tabulated  from  all  cases  of  diseases  of  the  palate,  with 
end-results. 

PAPILLOMA  OF  THE  PALATE 

PAPILLOMATA  of  the  palate  are  soft,  slender,  rounded  out- 
growths, having  a  body  and  a  pedicle.  These  growths  are 
not  rare.  They  are  attached  to  the  uvula  or  soft  palate  at 
its  free  edge — never  to  the  hard  palate.  They  grow  slowly. 
They  almost  never  occasion  disturbance  until  they  cause  a 
tickling  of  the  throat  and  a  cough.  They  occur  more  com- 
monly in  men  than  in  women.  It  is  wise  to  remove  these 
growths. 

DERMOID  TUMORS 

The  fact  that  the  region  of  the  palate  is  one  in  which 
there  is  an  infolding  of  fetal  structures  makes  it  not  at  all 
surprising  that  dermoid  tumors  are  found  here. 

Associated  with  these  congenital  growths  are  deformities 
of  the  jaws,  tongue,  and  lips.  The  cases  recorded  have  had 
points  of  attachment  to  the  hard  palate,  soft  palate,  and 
anterior  pillar  of  the  fauces.  Paget  records  a  few  cases. 

After  a  tumor  has  reached  a  certain  size  it  is  difficult  to 
determine  its  point  of  attachment  until  an  operation  is  done 
for  its  removal. 

319 


320 


TUMORS    OF   THE   JAWS 


SARCOMA  OF  THE  PALATE 

Sarcoma  of  the  palate  is  rather  rare.     It  usually  affects 
the  hard  palate.     The  tumor  does  not  tend  to  ulcerate,  as 


Fig.  305. — To  illustrate  the  frequent  seats  of  papillomata  of  the  palate 

carcinoma  does.     It  occurs  in  adults  and  old  people.     The 
glandular  enlargement  in  the  neck  is  not  infrequent. 

Round-cell  sarcoma  seems  more  common  than  any  other 
type  of  sarcoma. 


PLATE  VII 


A  telangiectatic  tumor  of  the  uvula  involving  the  palate.  Non-malignant. 
A  girl  eleven  years  old.  For  several  months  the  uvula  has  been  swollen 
and  bluish  in  color,  1%  inches  long  and  J^  inch  wide.  At  the  tip  and  sides 
of  the  uvula  are  several  reddish-blue  nodules  about  the  size  of  a  split-pea,  and 
many  small  enlarged  veins  appear  at  the  base  of  the  uvula.  (Case  of 
F.  L.  Jack.) 


TUMORS   OF   THE   PALATE 


321 


Christopher  Heath  records  two  cases,  one  in  an  adult 
and  one  in  a  child.  The  result  of  the  enucleation  and  cau- 
terization of  the  adult  tumor  is  not  stated.  The  child  died 
from  an  inoperable  growth. 

Sarcoma  at  an  early  stage  of  its  growth  is  difficult  to 


Fig.  305. — A.  S.     Sarcoma  of  the  hard  palate  (Massachusetts  General  Hos- 
pital clinic). 

differentiate  from  a  benign  tumor.     It  grows  rapidly  and 
may  ulcerate. 


Case  of  Sarcoma  of  the  Hard  Palate. — A.  S.  Massa- 
chusetts General  Hospital  clinic,  August  13,  1907.  Thirty- 
six  years  old,  married.  Five  months  previous  to  operation 
he  had  pain  in  the  left  upper  jaw  and  left  ear.  The  swell- 
ing appeared  in  the  hard  palate,  on  the  left  side.  It  was 
21 


322  TUMORS   OF   THE   JAWS 

excised,  but  it  returned.  The  external  carotid  was  clamped, 
and  the  left  upper  maxilla  was  removed.  He  recovered  from 
the  operation.  He  was  treated  by  the  x-ray  and  Coley's 
serum.  He  left  the  hospital  September  9,  1907,  having  re- 
currence in  both  the  mouth  and  the  pharynx. 


Fig.  307. — Melanosarcoma  of  the  upper  jaw,  starting  in  the  hard  palate. 
A  woman,  forty-seven  years  old  (from  Mikulicz  and  Michelson's  Atlas,  1892, 
Berlin). 

MELANOTIC  SARCOMA  OF  THE  PALATE 

At  the  Massachusetts  General  Hospital  clinic  no  cases 
of  melanotic  sarcoma  have  been  seen.  Gussenbauer,  Treves, 
Billroth,  Eisenmenger  (from  Albert's  clinic),  and  Volkmann 
(from  the  Marburg  clinic)  each  report  one  case. 

Billroth's  case  and  Albert's  case  were  each  inoperable. 
Round-  and  spindle-cells  predominated  in  the  tumors  ex- 
amined. 


TUMORS    OF    THE    PALATE  323 

Liebold  records  one  case — a  man  twenty-four  years  old, 
with  a  melanosarcoma  primary  in  the  hard  palate.  It  was 
excised.  It  recurred  in  three  months.  The  upper  jaw  was 
partially  resected,  and  the  microscope  showed  it  to  be  a 
spindle-cell  sarcoma  without  any  trace  of  pigment. 

In  two  and  one-half  months  there  was  another  local  re- 
currence. Another  portion  of  the  maxilla  and  of  the  nasal 
septum  were  removed.  This  time  the  microscope  showed 
the  recurrence  to  be  melanotic. 

Gussenbauer's  *  case  was  of  the  hard  and  soft  palate.  He 
removed  the  disease  (this  was  in  1886)  with  the  curet  and 
thermocautery.  Recurrence  took  place  in  four  years.  It  was 
excised  this  time  and  healed.  No  further  history  was  given. 

Trevesf  reports  a  case  of  melanotic  spindle-cell  sarcoma 
removed  from  the  hard  palate  of  a  woman  fifty-eight  years 
old.  Recurrence  appeared  within  a  year  in  the  right  nostril 
and  neck. 

CARCINOMA  OF  THE  PALATE  AND  UVULA 
Primary  carcinoma  of  the  palate  is  very  rare.  Fried- 
man:]: reports  a  case  of  primary  carcinoma  of  the  uvula  in  a 
man  of  forty-nine  whose  only  symptom  was  pain  on  swallow- 
ing. The  uvula  was  transformed  into  a  reddish-yellow 
tumor  about  the  size  of  a  cherry.  He  says  there  are  only 
four  other  cases  in  the  literature,  but  gives  no  references  and 
no  illustrations. 

Blauel  and  Vitaul§  record  one  case  of  primary  epithelioma 
of  the  soft  palate. 

*  Prag.  med.  Woch.,  Xov.  9,  1886,  vol.  iii,  p.  171. 
t  Brit.  Med.  Jour.,  1886,  vol.  ii,  p.  862. 
I  Berlin,  klin.  Woch.,  April  10,  1905,  vol.  xlii,  p.  444. 
§  Loire  med.,  1900,  vol.  xix,  pp.  120-127. 


324  TUMORS   OF   THE   JAWS 

Smith*  reports  a  case  of  primary  carcinoma  of  the  uvula 
in  a  man  of  fifty-one,  a  pipe-smoker,  whose  symptoms  were 
difficulty  in  swallowing  and  dryness  of  the  throat  for  nearly 
a  year.  On  the  uvula  was  a  strawberry-like  mass,  with 
some  erosion,  and  induration  extending  over  the  right  side 
of  the  soft  palate  for  half  an  inch.  The  tumor  was  removed, 
but  recurred  in  a  month.  After  a  more  extensive  removal  it 
recurred  again  in  three  months,  and  was  again  removed. 
Five  months  later  the  patient  was  well  and  free  from  re- 
currence. 

McCawf  reports  a  case  of  primary  carcinoma  of  the  uvula 
in  a  woman  of  thirty-seven  who,  for  eight  months,  had  slight 
throat  irritation  and  some  soreness.  She  had  a  mass  in- 
volving the  uvula,  velum  palati,  each  posterior  faucial 
pillar,  the  right  lateral  and  a  portion  of  the  posterior  wall  of 
the  pharynx.  The  growth  was  partly  excised,  cureted, 
cauterized,  and  she  was  treated  with  x-ray  for  six  months, 
at  the  end  of  which  time  she  was  said  to  be  cured.  McCaw 
says  there  are  40  other  similar  cases  in  the  literature,  but 
gives  no  references  or  illustrations. 

Squamous-cell  carcinoma  may  begin  in  either  the  hard 
or  soft  palate,  and  may  spread  to  any  adjacent  structures. 
It  forms  an  ulcer  with  indurated  base  and  elevated  edges. 
The  lymphatic  glands  of  the  neck  are  often  involved. 

Removal  of  Tumors  of  the  Palate. — All  benign  tumors 
may  be  excised  by  incision  near  their  attachments  or  they 
may  be  enucleated. 

All  malignant  tumors  should  be  given  a  wide  berth,  in- 
cluding much  sound  tissue  in  the  portion  excised. 

*  X.  Y.  Med.  Jour.,  April  29,  1905,  vol.  Ixxxi,  p.  850. 
t  Ibid.,  August  9,  1902.  vol.  Ixxvl  p.  225. 


TUMORS   OF   THE    PALATE  325 

Jacobson  believes  that  when  the  growth  is  large,  pre- 
liminary tracheotomy,  plugging  the  fauces,  slitting  the  cheek, 
and  ligating  the  external  carotid  are  all  necessary  to  insure  a 
radical  removal  of  the  disease.  Jacobson  has  one  case  each 
of  cancer  and  sarcoma  alive,  one  four  and  a  half  years,  and 
the  other  five  years,  after  operation. 

Whenever  the  growth  is  in  the  hard  palate,  it  will  be 
necessary  to  chisel  through  the  sound  bone.  Enucleation 
alone  will  be  unwise. 

Results  of  Operation  for  Malignant  Disease  of  the  Palate.— 
There  are,  unfortunately,  very  few  cures  following  operations 
for  carcinoma  and  sarcoma  of  the  palate.  In  cases  followed 
for  some  months  after  operation  recurrence  is  found  to  have 
taken  place. 

MIXED  TUMORS  OF  THE  PALATE 

SYNONYMS  :  Endothelioma,  adenoma,  perithelioma,  plexi- 
form  sarcoma,  cylindroma,  palatal  epithelioma,  glandular 
enchondroma. 

Pathology. — These  are  growths  of  the  palate  which  form 
a  group  of  tumors  having  a  distinct  clinical  picture,  and 
being  among  the  rarer  tumors  occurring  in  the  palate.  It  is 
essentially  the  same  tumor  which  is  found  in  the  parotid, 
and  which  is  known  as  a  mixed  tumor. 

Volkmann,*  in  an  extensive  study,  reports  at  some  length 
6  cases  and  tabulates  138  others. 

Eisenmengerf  records  12  cases  in  1894. 

PagetJ  records  31  cases. 

*  Volkmann:  Deut.  Zeit.  f.  Chir.,  vol.  xli,  p.  1. 

f  Eisenmenger:  Ibid.,  vol.  xxxix,  p.  1. 

I  Paget:  St.  Bartholomew's  Hosp.  Reports,  1886,  vol.  xxii,  p.  315. 


326 


TUMORS    OF    THE    JAWS 


Larabee*  presents  9  cases  of  palatal  tumors  of  this  general 
type,  and  presents  the  French  view  as  to  their  epithelial 
origin. 

Wood,t  from  a  study  of  the  mixed  tumors  of  the  salivary 
glands  and  palate,  concludes  that — "  There  is  a  group  of 
extremely  complicated  tumors  occurring  in  the  facial  region 
which  contain  elements  from  both  epiblast  and  mesoblast 
in  most  intimate  relation  to  each  other. 


Fig.  308. — Sagittal  section  through  the  middle  of  the  left  upper  jaw. 
The  osseous  envelop  of  the  tumor  and  the  mucosa,  ulcerated  at  the  lowest 
point,  are  well  shown.  A  mixed  tumor — endothelioma  (H.  Coenen). 


"The  complicated  structure  of  the  stroma,  containing, 
as  it  does,  elements  such  as  embryonic  connective  tissue, 
cartilage,  bone,  fat,  lymphoid  tissue,  and  very  rarely  striated 
muscle,  is  explained  most  easily  by  the  assumption  of  an 
embryonic  misplacement  of  mesoblast. 

"The  structure  of  the  parenchyma  is  so  slightly  charac- 
teristic in  morphology  that  its  epithelial  nature  can  only  be 
considered  probable.  The  form  and  relationship  of  the  cells 

*  Larabee:  Arch.  Gen.  de  Med.,  1890,  vol.  i,  pp.  537-677. 
t  Annals  of  Surgery,  Philadelphia,  1904,  vol.  xxxix,  p.  57. 


TUMORS    OF    THE    PALATE 


327 


of  the  parenchyma  do  not  furnish  sufficient  data  to  justify 
these  cells  as  being  of  endothelial  origin. 

"The  theory  of  early  embryonic  displacement  of  epi- 
blastic  tissue  during  the  process  of  formation  of  the  parotid 
and  submaxillary  glands  and  the  branchial  arches  may  ac- 


Fig.  309. — Shows  a  mixed  tumor  of  the  palate  in  situ — "a  cylindroma." 
A  man,  forty-nine  years  old.  Tumor  is  hard  and  elastic.  Is  up  against  the 
left  alveolus,  not  touching  the  right  side.  The  nose  is  free.  There  are  no 
glands.  Operation,  but  sufficient  time  has  not  elapsed  to  report  (Coenen). 

count  for  many  of  the  morphologic  peculiarities  of  the  cells 
of  these  tumors,  especially  the  lack  of  many  typical  features 
which  we  associate  with  epithelioma." 

Three  distinct  opinions  are,  therefore,  held  as  to  the  origin 
of  these  mixed  tumors:  (1)  The  German  pathologists  believe 


328  TUMORS   OF   THE   JAWS 

them  to  be  endothelial  in  origin.  Volkmann  and  his  suc- 
cessors hold  to  this  explanation,  that  they  are  endothelial  in 
nature  and  derived  from  the  endothelium  of  the  lymph- 
spaces;  (2)  the  French  school  believes  that  they  are  epithe- 
lial, and  derived  either  from  a  misplaced  portion  of  the 
parotid  or  from  a  misplacement  of  the  mesoblast  and  epi- 
blast;  (3)  there  is  a  third  theory,  that  the  tumors  contain 
both  endothelial  and  epithelial  elements.  This  latter  theory 
seems  the  most  satisfactory. 

It  is  difficult  to  apply  a  suitable  name  to  this  group  of 
tumors.  It  seems,  from  a  study  of  the  evidence  as  presented 
by  Wood,  that  the  term  mixed  tumor  is  the  most  satisfactory. 
As  Wood  points  out — "The  problem  of  the  exact  nature  of 
these  growths  cannot  be  definitely  settled  so  long  as  we  must 
rest  our  distinctions  upon  morphologic  or  histologic  differ- 
ences." 

So  far  as  the  explanation  of  the  presence  of  cartilage  in 
these  tumors  is  concerned,  the  main  weight  of  the  evidence 
seems  to  be  on  the  side  of  the  theory  of  the  congenital  mis- 
placement of  cells  which  have  the  power  to  form  either  car- 
tilage or  myxomatous  tissue. 

Clinically,  these  mixed  tumors  of  the  palate  are  found 
more  commonly  in  the  soft  than  in  the  hard  palate,  and  upon 
the  left  side  more  frequently  than  upon  the  right  side.  They 
are  never  found  in  the  median  line.  They  occur  in  young 
and  middle-aged  individuals,  and  occasionally  in  youth  and 
old  age;  the  middle  period  of  thirty-five  to  fifty  seems  to  be 
the  customary  one. 

Ordinarily  they  present  as  tumors  of  small  size — as  large 
as  a  walnut,  a  hazel-nut,  or  an  olive.  They  are  usually 
rounded  or  oval,  nodular  or  lobular,  circumscribed,  slightly 


TUMORS    OF   THE    PALATE  329 

movable,  smooth,  and  elastic,  sometimes  displacing  the 
uvula.  The  mucous  membrane  covering  the  tumor  is 
smooth,  normal  in  color,  and  movable,  usually  without 
ulceration,  and  perhaps  showing  one  or  two  enlarged  veins. 
There  is  ordinarily  no  glandular  enlargement. 

If  the  tumor  contains  much  fibrous  tissue,  it  is  firm.  If 
the  tumor  contains  cartilage  and  little  else,  it  is  distinctly 
harder.  If  it  be  made  up  of  more  cellular  elements,  even 
with  a  few  scattered  hyaline  cartilage  islets,  it  is  soft  to 
palpation. 

These  tumors  are  quiescent  tumors,  existing  possibly 
unrecognized  by  the  patient  for  many  years.  They  are 
usually  painless  growths.  They  cause  little  discomfort  until 
they  attain  some  size,  and  become,  from  their  mere  mechanic 
presence,  disturbing  to  speech,  to  deglutition,  or  to  breathing. 

As  Paget  has  pointed  out,  if  the  tumor  advances  toward 
the  tonsil,  it  becomes  ill  defined,  is  without  its  capsule,  and 
this  method  of  growth  is  a  bad  sign.  If  the  tumor  advances 
forward,  lying  in  the  soft  or  hard  palate,  or  moves  inward 
toward  the  median  line,  it  probably  will  shell  out — it  can  be 
more  readily  enucleated  than  the  tumor  of  the  first  type. 

The  lymphatic  glands  are  almost  never  involved.  The 
metastases  of  these  mixed  tumors  are  local  and  remote. 
The  local  recurrence  is  of  the  same  type  as  the  original 
tumor.  When  the  recurrences  extend  over  a  long  period, 
the  tumor  gradually  may  lose  its  characteristic  morphology 
and  resemble  a  sarcoma.  If  the  capsule  of  the  tumor  is 
penetrated  and  the  growth  is  at  all  vascular,  it  may  recur 
and  spread  rather  rapidly,  thus  giving  it  a  malignant  type. 
These  cases  then  resemble  sarcomata  very  closely. 

The  malignancy  of  any  of  these  tumors  may  be  intimated 


330  TUMORS    OF   THE   JAWS 

roughly  by  its  physical  characteristics.  The  firm,  slowly 
growing  tumors  will  be  most  benign,  while  the  softer,  more 
rapidly  growing  tumors  will  be  malignant.  No  explanation 
has  yet  been  given  for  a  sudden  change  from  apparent 
benignity  to  one  of  very  great  malignancy. 

These  mixed  tumors,  if  enucleated,  do  not  tend  to  recur. 
If,  for  any  reason,  they  are  not  easy  to  enucleate,  recurrence 
is  likely. 

The  7  cases  of  enchondromata  *  and  cylindromata  re- 
corded by  Hoffmann  are  undoubtedly  instances  of  the  mixed 
tumors  described  above.  Three  of  these  cases  had  their 
origin  in  the  soft  and  3  in  the  hard  palate.  Of  the  first  3, 
which  seemed  to  be  pure  enchondromata,  1  recurred,  and 
the  patient  finally  died  after  total  resection  of  the  upper  jaw. 

One  of  the  7  cases  occurred  in  the  Jena  clinic.  He  was  a 
man  of  fifty-six  years.  The  tumor  of  the  palate  had  existed 
two  years.  It  was  removed  by  partial  excision,  leaving  the 
soft  palate.  Recurrence  took  place  after  one  month.  The 
Paquelin  cautery  destroyed  this  recurrence,  and  the  patient 
is  alive  one  and  a  half  years  after  the  cauterization,  without 
further  recurrence. 

PALATAL  TUMORS  AT  THE  MASSACHUSETTS  GENERAL  HOSPITAL 

CLINIC 

I  have  discovered  17  cases  of  palate  tumor  in  the  records 
of  the  hospital  for  the  last  few  years.  Doubtless  other  cases 
have  come  to  the  throat  department  clinic  which  have  never 
been  admitted  to  the  hospital  for  operative  treatment.  Of 
these  17  cases,  inquiry  was  made  by  letter.  Seven  letters 
were  returned  unanswered.  Five  cases  could  not  be  heard 
from,  leaving  a  reply  from  5  of  the  17. 

*  Langenbeck:  Arch.  f.  klin.  Chir.,  vol.  xxxviii,  p.  98. 


TUMORS    OF   THE    PALATE  331 

The  facts  about  these  5  cases  are  as  follows : 

CASE  1. — B.  C.  Hospital  Record,  vol.  cc,  p.  245.  Man, 
thirty-six  years  old.  Had  for  five  months  a  rapidly  growing 
pedunculated  tumor,  the  size  of  a  small  hen's  egg,  upon  the 
right  side  of  the  hard  palate.  This  was  removed  and  recurred 
one  month  later,  when  it  was  again  excised,  and  the  base  of 
the  growth  cauterized  with  the  actual  cautery.  The  tumor 
was  a  benign  growth. 

Nineteen  years  later  there  had  been  no  recurrence  of  the 
growth.  The  man  was  then  killed  accidentally. 

CASE  2. — C.  T.  P.  Hospital  Record,  vol.  cccxciii,  p. 
174.  A  man,  seventy-three  years  old,  had  for  two  years  a 
slowly  progressive  ulceration  near  the  posterior  edge  of  the 
hard  palate,  just  to  the  median  line,  with  slightly  indurated, 
elevated  margin.  This  ulcer  was  the  size  of  a  nickel.  The 
bone  was  uninvolved.  No  cervical  lymphatic  glands  were 
enlarged. 

This  man  was  a  constant  pipe-smoker  and  wore  a  plate 
of  false  teeth. 

The  ulcer  was  excised.  Upon  examination  it  proved  to 
be  an  epithelioma.  Six  months  later  he  died  of  a  severe 
recurrence  of  the  growth.  Jf-ray  treatment  did  him  no  good. 

CASE  3. — L.  A.  R.  Hospital  Record,  vol.  xxxvii,  p. 
122.  A  woman,  sixty-nine  years  old,  had  for  six  years  a 
slowly  growing  tumor  on  the  right  side  of  the  soft  palate, 
involving  the  pillar  of  the  fauces.  It  was  the  size  of  a 
walnut,  firm,  resistant,  and  not  tender. 

The  tumor  was  excised.  The  pathologic  report  from 
W.  F.  Whitney,  pathologist  to  the  hospital,  stated  that  it 
was  an  epidermoid  cancer. 

Eight  years  subsequently  she  reports  no  recurrence  of 
the  tumor  of  the  palate.  She  has  had  a  second  operation 
for  epithelioma  of  the  skin  of  the  eyelid. 


332 


TUMORS   OF   THE   JAWS 


CASE  4. — M.  E.  F.  Hospital  Record,  vol.  cclxii,  p. 
214.  A  woman,  twenty-seven  years  old,  had  an  extensive 
ulceration  of  the  hard  palate  for  one  and  a  half  years.  A 
partial  resection  of  the  upper  jaw  was  done.  Diagnosis, 
tuberculosis. 

Recurrence  in  the  nose.  The  palatal  tuberculosis  has 
been  held  in  check  by  constant  treatment.  She  has  never 
been  free  from  the  disease  during  the  past  seventeen  years, 
but  has  been  under  constant  treatment,  either  in  this  country 
(America)  or  in  Turkey. 

CASE  5. — S.  E.  W.  Hospital  Record,  vol.  clxxxvii,  p. 
253.  A  boy,  eighteen  years  old,  has  had  a  rapidly  growing 
tumor  for  one  year,  occupying  the  front  and  upper  part  of 
the  mouth,  the  hard  palate,  and  involving  the  space  of 
the  three  front  teeth.  The  growth  has  been  twice  cau- 
terized, but  has  each  time  recurred.  It  was  then  excised 
with  the  underlying  bone  and  true  teeth.  It  was  an  epithe- 
lioma.  Twenty-eight  years  later  there  is  no  recurrence  and 
he  is  in  good  health. 

CASES     OF    TUMOR    OF    THE     PALATE    FROM    THE     MASSA- 
CHUSETTS GENERAL  HOSPITAL  CLINIC 


a   . 
2  o 
0* 

SEX. 

AGE. 

LOCATION. 

DURA- 
TION. 

OPERATION. 

RECUR    PATHOL- 
RENCE.        OGY. 

RESULT. 

1 

Male. 

36 

Hard  palate 

5 

Excised. 

Yes.       Benign. 

Died  after  nine- 

(right). 

mos.      Excised,      cau- 

No. 

teen  years,  ac- 

tery. 

cidentally. 

2     Male. 

73 

Hard  palate 

2         Excised. 

Yes      Epitheli-     Deadsix  months 

(posterior)  . 

yrs. 

in  6 

onia.            later     of     dis- 

mos. 

ease. 

3     Female.     69 

Soft  palate. 

6 

Excised. 

No.      Epitheli-     Well  eight  years 

Right  side. 

yrs. 

oma.            after. 

No  ulcer. 

4     FemaJe. 

27 

Hard    pal- 

\]/i      Partial       exci- 

Yes.      Tubercu-   Living        seven- 

• 

ate.    Ul- 

yrs. 

sion  of  upper 

losis.           teenyears  later, 

ceration. 

jaw. 

' 

with    extensive 

disease. 

5 

Male. 

18 

Hard    pal- 

1  yr. 

Cauterization. 

Yes.      Epitheli- 

Twenty-  ei  g  h  t 

ate. 

Excised  with 

No.         oma. 

years  later  no 

Anteriorly 

teeth. 

recu  r  re  nee. 

(tumor). 

Well. 

CHAPTER  VIII 
LEONTIASIS  OSSEA* 

CONTENTS  OF  CHAPTER:  Definition. — Etiology. — Pathology. — Symptoms. — 
Course  of  the  disease. — Treatment. — Relief  from  cerebral  compression: 
A  study  of  reported  cases  (Kanavel). — Intervention  in  cases  of  contrac- 
tion of  the  orbital  cavities:  Study  of  case  reports  (Kanavel). — Involve- 
ment of  the  nasal  fossa?. 

LEONTIASIS  ossea  (Virchow)  is  a  localized  or  diffuse 
hyperostosis  of  any  or  all  the  bones  of  the  cranium  and  face. 
It  so  uniformly  involves  the  jaws,  both  upper  and  lower,  that 
it  is  very  properly  considered  here.  Moreover,  there  are 
certain  direct  operative  surgical  problems  involved,  which, 
although  not  possible  to  settle  at  once,  are  important  to 
discuss. 

Ziegler  speaks  of  the  disease  as  a  partial  gigantism  which 
affects  the  bones  of  the  cranial  vault,  as  well  as  those  of  the 
face. 

The  etiology  is  obscure.  The  disease  usually  begins 
about  puberty,  with  an  insidious  onset.  Virchow  believed 
it  might  be  due  to  an  inflammatory  process — possibly  to  an 
infection  of  some  sort.  A  primary  trauma,  rachitis,  tuber- 
culosis, syphilis,  a  trophic  disease,  bear  no  likely  relation  to 
the  origin  of  this  malady,  although  each  has  been  thought  to 
be  of  etiologic  moment  by  different  observers. 

The  disease  corresponds  to  elephantiasis  in  the  soft  parts. 
Acromegaly  and  von  Recklinghausen's  disease  have  little  in 
common  with  it. 

*  The  material  for  this  chapter  has  been  taken  very  largely  from  the  recent 
complete  study  by  Kanavel  (Surgery,  Gynecology,  and  Obstetrics,  June, 
1907). 

333 


334 


TUMORS    OF   THE   JAWS 


Pathology. — According    to    Simmons,    pathologically, 
leontiasis  has  been  termed  a  hypertrophy,  a  form  of  new- 


Fig.  310.— Case  of  le- 
ontiasis ossea  (Beck).  A 
widow,  thirty-nine  years 
old;  eighteen  months'  du- 
ration. Tissues  were  re- 
moved to  relieve  pain.  No 
lime  salts  were  |  present. 
The  finger-tips  were  bulb- 
ous. The  bony  phalanges 
were  without  lime  salts. 


Fig.  311.— Case  of  le- 
ontiasis ossea.  The  pos- 
terior view  of  Fig.  310 
(Beck). 


growth,  and  an  ostitis,  but 
at  present  it  certainly  can- 
not be  regarded  as  either  of 
the  first  two  of  these,  and 
there  is  some  question  as  to 
whether  it  is  an  ostitis,  although  the  changes  are  strictly 


LEONTIASIS   OSSEA 


335 


Fig.  312. — Case  of  leontia- 
sis  ossea.  Note  bulbous  fingers 
and  the  tumor  of  upper  jaw 
(Beck). 


Fig.  313. — Case  of  leontiasis 
ossea.  Another  view  of  case  in  Fig. 
312  (Beck). 


Fig.  314.— Case  of  leontiasis  ossea.  •  A  lateral  view  of  case  in  Fig.  312  (Beck), 


336 


TUMORS    OF    THE    JAWS 


of  an  inflammatory  character.  The  process  begins  usu- 
ally in  the  upper  jaw,  near  the  nasal  spine,  more  com- 
monly on  the  right  side,  but  it  soon  becomes  symmetric, 
although  it  may  start  in  the  frontal  bone,  or,  rarely,  in  the 
lower  jaw.  Later,  as  the  disease  progresses,  all  the  bones 
of  the  face,  as  well  as  those  of  the  cranium,  are  involved 
to  a  greater  or  less  extent,  the  anterior  portion  showing 
usually  the  most  change. 


FsM$/-« 


>«,.   *  ~  * 
*  ' 


Fig.  315. — Drawing  from  tumor  seen  in  Fig.  312,  at  its  periphery,  show- 
ing red  blood-corpuscles  in  the  lacunar  spaces  (Leitz  obj.  No.  7;  eyepiece 
No.  4;  tubejength,  160  mm.)  (Beck). 


In  the  advanced  cases  the  bones  are  all  thickened,  and 
those  of  the  face  are  distorted,  showing  hyperostoses  and 
eroded  surfaces  as  the  result  of  periostitis.  The  skull,  on 
account  of  this  thickening,  is  much  increased  in  weight,  the 
dried  specimen  often  weighing  five  kilograms,  or  five  times  as 
much  as'the  normal.  (See  Figs.  318,  319.)  The  appearance 


LEONTIASIS   OSSEA 


337 


of  the  bone  is  that  which  results  from  an  ostitis,  and  in  this 
respect  the  skulls  somewhat  resemble  those  observed  in 
hereditary  syphilis.  In  the  vertex,  where  the  process  can 
best  be  studied,  the  bone  is  often  four  centimeters  in  thickness. 
This  new  formation  of  bone  takes  place  on  both  the  inner 
and  the  outer  tables,  with  a  corresponding  increase  in  the 
girth  of  the  head  and  a  diminution  in  size  of  the  brain  cavity, 


..  • 
i  '•'  •  •    •  .  ? ' 

.-.    . 


• 


Fig.  316. — Showing  microscopic  appearance  of  tissue  removed  from  case  seen 
in  Fig.  312  (Leitz  obj.  No.  3;  ocular  No.  4;  tube  length,  170  mm.)  (Beck). 


into  which,  at  times,  small  hyperostoses  project.  The  bone 
is  of  almost  ivory-like  hardness,  and  the  diploe  is  usually 
obliterated,  the  growth,  therefore,  being  both  an  exostosis 
and  an  enostosis.  In  acromegaly  and  hypertrophic  condi- 
tions, on  the  other  hand,  the  relation  of  the  diploe  to  the 
cortical  bone  is  approximately  normal,  and  the  cortical  bone 
is  of  normal  consistence.  At  the  base  of  the  skull  the  changes 

22 


338  TUMORS   OF   THE   JAWS 

are,  as  a  rule,  very  slightly  marked,  and  it  is  a  fact  that  the 
foramina  are  usually  of  normal  diameter  in  spite  of  the 
thickened  bone.  In  some  cases  the  sella  turcica  has  been 
narrowed,  while  in  others  it  is  somewhat  increased  in  size. 


Fig.  317. — X-ray  of  hand  of  case  seen  in  Fig.  312.     Note  terminal  phalanges. 
Bone  salts  have  evidently  disappeared  from  terminal  phalanges  (Beck). 


In  the  upper  jaw  the  pathologic  process  appears  as  a 
diffuse  thickening  of  the  entire  bone,  in  the  form  of  enostoses 
and  exostoses,  and  occasionally  as  tuberous  prominences, 
the  latter  being  seen  near  the  nasal  spine,  where  the  process 
commonly  begins,  or  over  the  malar  bone.  This  increase  in 


LEONTIASIS   OSSEA  339 

the  size  of  the  bone  may  fill  up  the  antrum  or  block  the  nasal 
cavity,  in  which  case  necrosis  and  changes  due  to  secondary 
infections  are  commonly  seen.  If  the  hard  palate  is  in- 
volved, it  may  be  pushed  down  into  the  mouth  to  the  level 
of  the  borders  of  the  alveolar  process,  and  involvement  of 
the  latter  is  associated  with  a  loss  of  the  teeth.  Growth  into 
the  orbit  from  either  the  superior  maxilla,  the  frontal  bone,  or 
the  sphenoid  causes  a  narrowing  of  that  cavity,  forcing  the 
eye  out.  In  the  frontal  bone  there  is  often  an  associated 
inflammation  of  the  sinus. 

The  other  bones  of  the  body  are  usually  normal,  and 
changes  of  the  soft  parts,  except  those  secondary  to  pressure 
and  sepsis,  are  practically  unknown.  Starr,  however,  men- 
tions a  case  in  which  there  was  some  extension  of  the 
process  to  the  two  upper  vertebrae. 

Pathologically,  then,  this  disease  is  a  new-formation  of 
tissue  resulting  in  a  possible  myxo-chondro-osteo-fibromatous 
new-formation. 

Symptoms. — The  disease  usually  begins  insidiously  dur- 
ing the  early  years  of  life.  Simmons,  from  a  study  of  the 
literature,  finds  that  it  may  begin  in  the  spine  of  the  superior 
maxilla,  causing  an  appearance  of  flattening  of  the  base  of 
the  nose.  From  this  starting-point  it  progresses  slowly  and 
symmetrically  to  the  frontal  bone  and  jaws. 

If  the  nasal  cavity  becomes  involved,  it  may  be  closed, 
resulting  in  anosmia,  or  a  nasal  discharge  dependent  upon  an 
infection  of  the  antrum  of  Highmore. 

Neuralgic  pains  in  the  face  are  noticed.  Optic  neuritis 
is  sometimes  found,  due  to  various  causes.  Epiphora  is 
occasionally  present.  Proptosis  is  not  uncommon.  Certain 
symptoms  due  to  cerebral  compression  may  exist,  viz., 


340  TUMORS    OF    THE    JAWS 

convulsions,  mental  impairment  even  to  dementia,  head- 
aches. Eye  symptoms  were  notably  absent  in  many  of  these 
cases,  with  symptoms  associated  with  possible  cerebral 
compression.  The  eye  symptoms  may  have  been  due  to 


Fig.    318. — Leontiasis  ossea  (Army  Medical  Museum,  Washington,  D.  C.). 

changes  in  the  orbital  cavities  and  not  to  the  intracranial 
compression. 

Deafness  and  vertigo  are  sometimes  present,  as  well  as 
tinnitus  aurium  and  paralysis  of  the  cranial  nerves. 


LEONTIASIS    OSSEA  341 

The  course  of  the  disease  is  slow,  and,  according  to 
Kanavel,  may  become  arrested  at  any  stage,  while  accord- 


Fig.    319. — Leontiasis  ossea  (Army  Medical  Museum,  Washington,  D.  C.)- 

ing  to  Simmons,  the  disease  is  always  fatal — there  is  never 
retrogression. 


342  TUMORS    OF   THE   JAWS 

The  symptoms  are  the  deformed  appearances  and  those 
occasioned  by  an  encroachment  of  the  bony  growth  upon 
parts  contiguous  to  it. 

Treatment.* — According  to  most  observers,  no  treat- 
ment is  of  any  avail.  When  the  disease  is  recognized  early 
and  when  it  is  confined  to  one  jaw,  excision  of  that  jaw  has 
been  done  to  relieve  pressure  upon  the  eye  and  nose. 

No  operative  procedure  is  available  to  cure  the  disease. 
Kanavel  advocates  a  decompression  operation  for  the  relief 
of  intracranial  pressure. 

"The  most  serious  sequelae  appear  because  of  contraction 
of  the  nasal  fossae,  the  orbital  cavities,  and  the  cranium; 
the  long  course  of  the  disease,  and  its  arrest  at  certain  stages, 
offer  hope  that  if  these  complications  can  be  removed,  the 
patient's  life  and  general  health  may  be  preserved  for  a 
number  of  years,  and  in  case  of  arrest,  permanent  relief  from 
symptoms  may  be  hoped  for"  (Kanavel). 

Fifteen  of  the  cases  analyzed  showed  symptoms  that 
might  be  attributed  to  cerebral  compression.  No  operation 
was  deliberately  planned  for  the  relief  of  compression. 

Relief  from  Cerebral  Compression. — Owing  to  the 
importance  of  this  question,  it  will  be  studied  in  some  detail. 

As  before  mentioned,  15  cases  showed  symptoms  that 
could  be  attributed  to  cerebral  compression,  but  in  no  case 
was  operation  performed  with  the  deliberate  intention  of 
relieving  it.  Kanavel's  study  of  the  reported  cases  is  as 
follows : 

The  first  case  of  Horsley  (case  1)  was  observed  when  the 
patient  was  nineteen  years  of  age,  and  he  had  complained  of 

*  The  study  by  Kanavel  (Surgery,  Gynecology,  and  Obstetrics,  June. 
1907)  is  here  quoted  in  detail  as  the  latest  statement  of  the  facts. 


LEONTIASIS   OSSEA  343 

headache,  with  vomiting  and  epileptic  fits,  for  five  years; 
there  is  no  history  of  optic  neuritis.  The  swelling  involved 
the  left  eyebrow  most,  but  extended  to  the  left  parietal  and 
occipital  region.  The  right  temporal  and  parietal  bones 
were  distinctly  involved.  The  growth  projected  into  the 
orbits  and  pushed  the  eyes  downward.  Here  was  a  case  in 
which  decompressive  operation  could  undoubtedly  have  been 
done  with  hope  of  relief,  and  Horsley  himself  states  that  it 
should  have  been  undertaken. 

In  Horsley 's  fourth  case  (case  3)  he  had  an  opportunity 
to  operate  upon  a  patient  who  complained  of  pain  in  both 
frontal  regions.  One  year  later  the  patient  was  well,  except 
for  pain  over  the  right  side.  The  operation  is  described  in 
detail  later. 

Sattler's  case  (case  8),  unfortunately,  showed  no  symp- 
toms of  cerebral  compression  except  an  optic  neuritis,  and, 
owing  to  the  distortion  of  the  orbital  cavities  and  proptosis, 
this  might  have  been  construed  as  being  due  to  the  latter,  so 
that  the  diagnosis  of  cerebral  compression  and  the  conse- 
quent necessity  of  decompressive  operation  would  have  been 
difficult  to  arrive  at.  The  patient  was  active  and  cheerful 
until  the  convulsive  seizures  and  coma  developed,  which 
ended  in  death  after  the  disease  had  been  observed  nine 
years.  At  postmortem  compression  of  the  brain  was  demon- 
strated. Operation  would  certainly  seem  to  have  been  indi- 
cated upon  the  orbits,  and  the  condition  found  at  operation 
might  have  demonstrated  the  necessity  of  furtner  operative 
procedure  of  decompressive  nature,  if  the  possibility  of  such 
had  been  kept  in  mind  by  the  surgeon. 

Keen's  case  will  be  mentioned  later,  under  the  discussion 
of  operation  in  the  presence  of  eye  signs. 


344  TUMORS    OF   THE   JAWS 

Starr's  patient  (case  14)  complained  of  numbness  and 
impaired  gait.  No  mention  is  made  as  to  eye  symptoms. 
All  the  bones  of  the  skull  and  face  were  involved,  and  the 
possibility  of  decompressive  operation  should  be  considered. 
The  same  should  be  said  concerning  Putnam's  first  case 
(case  17). 

Putnam's  second  case  (case  18)  might  have  been  operated 
upon  with  hope  of  relief.  The  history  states  that  the  pa- 
tient had  repeated  convulsions,  and  the  mental  condition 
was  constantly  growing  worse.  Headaches  were  frequent. 
The  forehead  was  prominent,  with  two  broad  exostoses  or 
thickenings  on  the  skull,  2J/2  inches  across.  The  patient 
had  an  optic  neuritis. 

Prince's  case  (case  21)  presented  the  same  indication. 
This  was  admitted  by  Dr.  Prince  at  the  postmortem,  since' 
owing  to  the  simultaneous  thickening  of  the  orbital  plate 
of  the  frontal  bone  and  the  vertex,  the  frontal  lobes  were 
greatly  compressed.  Partial  atrophy  of  the  right  optic  nerve 
was  present.  There  was  some  proptosis,  however. 

Wrany's  case  (case  24)  showed  cerebral  symptoms.  The 
vascular  and  nerve-canals  were  not  contracted,  and  it  is 
probable  that  palliative  operation  would  have  given  con- 
siderable relief  to  the  symptoms  and  prolonged  life. 

Schutzenberger's  case  (case  25)  stands  as  a  conspicuous 
example  of  possible  palliation  by  decompressive  procedures. 
The  patient  came  under  observation  because  of  cerebral 
symptoms:  epilepsy,  headache,  and  final  dementia.  At 
postmortem  none  of  the  foramina,  except  the  left  posterior 
jugular  foramen,  was  contracted.  The  anterior  portion  of 
the  skull  particularly  was  involved. 

Kanavel  concludes:  Thus  we  see  that  of  the  15  cases  men- 


LEONTIASIS   OSSEA  345 

tioned  as  showing  symptoms  of  cerebral  compression,  there 
is  justification  for  assuming  that  palliative  operation  might 
have  relieved  the  patients  for  years,  and  in  9  of  these  there 
were  symptoms  which  should  have  suggested  the  advisa- 
bility of  operation.  Case  3  was  operated  upon  by  Horsley, 
not  with  the  idea  of  cerebral  decompression,  however,  while 
cases  18,  21,  24,  and  25  were  conspicuous  examples  of  cases 
that  could  not  only  have  been  diagnosed,  but  also  might 
have  been  operated  upon  with  every  hope  of  success. 

Intervention  in  Cases  of  Contraction  of  the  Orbital 
Cavities. — Kanavel  says:  The  discussion  of  this  phase  of 
the  question  is  of  great  interest,  since  definite  results  can  be 
promised.  Of  the  34  cases,  17  showed  involvement  of  the 
orbital  cavities.  Putnam's  cases  (3  and  4),  Astley  Cooper's 
case,  and  Stack's  cases  (cases  9,  19,  20,  and  27)  showed  some 
thickening  of  the  orbit,  but  no  demonstrable  change  in  the 
eye  or  its  function.  In  the  remaining  13  the  information  as 
to  the  optic  neuritis  is  often  indefinite;  the  description, 
however,  is  as  follows: 

Horsley  (case  1) :  Eyes  pushed  downward. 

Horsley  (case  2) :  Proptosis  of  right  eye ;  no  diplopia ;  right 
eye  has  only  perception  of  light,  and  left,  impaired  vision. 

Horsley  (case  4) :  Right  eye  depressed  and  somewhat 
protruded;  no  diplopia;  no  change  in  fundus. 

Sattler  (case  8) :  Epiphora  at  the  age  of  eleven,  propto- 
sis  of  both  eyes  at  the  age  of  fifteen,  and  optic  atrophy,  most 
marked  in  the  left,  at  nineteen. 

Keen  (case  11):  Eyes  pushed  downward  and  forward; 
no  optic  neuritis  present.  This  case  was  operated  upon  and 
will  be  discussed  later. 

Gunn  (case  15):  Proptosis;  optic  disc  atrophied. 


346  TUMORS   OF   THE   JAWS 

Putnam  (case  18):  Eyes  prominent;  optic  neuritis  of 
right  eye;  eyesight  failed  years  afterward. 

Prince  (case  21):  Eyes  prominent;  orbital  cavities  di- 
minished in  size,  and  partial  optic  atrophy  in  right. 

Edes  (case  22) :  Eyes  somewhat  prominent ;  double  optic 
atrophy. 

Ribel  (case  23) :  Proptosis  after  thirty. 

Howslip  (case  28) :  Proptosis  and  impaired  vision. 

Kanavel  continues :  Thus  we  see  that  involvement  of  the 
orbits  is  an  early  and  progressive  change.  The  eyes  are 
pushed  out  by  the  increasing  bony  deposit,  and  the  fre- 
quent association  of  optic  neuritis  and  displacement  of  the 
eyes  leads  us  to  consider  this  as  of  as  much  importance  as 
the  cerebral  compression  in  the  production  of  blindness. 

When  we  consider  the  anatomy  of  the  orbit  and  the  rela- 
tions of  its  vessels  and  nerves,  we  see  that  a  considerable 
portion  can  be  removed  from  the  outer  part  and  roof,  giving 
relief  to  the  contracted  orbit.  The  removal  of  bone  can  be 
continued  over  to  the  optic  foramen,  releasing  the  optic 
nerve  and  artery  if  they  be  compressed.  In  two  cases  iso- 
lated hypertrophic  bone  has  been  removed,  incidentally  re- 
lieving the  eye,  although  that  may  not  have  been  the  primary 
object  of  the  operation.  As  long  as  these  patients  have  been 
observed,  however,  no  eye  symptoms  have  developed. 

Horsley's  case  (case  4)  showed  the  right  eye  depressed 
one-half  inch  and  somewhat  protruded.  There  was  no 
optic  neuritis,  however,  although  there  was  impaired  vision, 
and  the  operation  doubtless  prevented  changes,  for  years,  at 
least.  The  tumor  involved  the  whole  frontal  region  on  the 
right  side. 

KanavePs  study  of  the  other  cases  previously  classified 


LEONTIASIS   OSSEA  347 

demonstrates  that  an  operative  procedure  could  have  been 
instituted  in  like  manner.  In  Battler's  case,  for  instance, 
proptosis  developed  at  the  age  of  fifteen,  while  optic  atrophy 
did  not  appear  until  nineteen.  Displacement  practically 
always  precedes  the  destruction  of  the  nerve,  and  offers  a 
clear  indication  for  operation,  with  every  hope  of  preserving 
the  function  of  the  eye.  Horsley  himself  states  that  his 
first  case  (case  1)  should  have  been  operated  upon.  It  is 
possible  that  in  cases  of  extensive  involvement  operation  in 
stages  may  be  indicated. 

Involvement  of  the  Nasal  Fossae. — Kanavel  finds  that 
this  complication  is  undoubtedly  present  much  oftener  than 
the  histories  show.  While  it  is  not  so  serious  as  the  preceding 
sequelae,  yet  the  patients  often  complain  bitterly  of  the  nasal 
obstruction  and  continual  discharge  which  the  obstruction 
produces.  Anosmia,  while  frequently  present,  would  be  sel- 
dom complained  of  by  the  patient.  The  involvement  of  the 
tear-duct  is  a  more  serious  disaster,  for  which  intervention 
could  probably  offer  slight  hope  of  relief.  Epiphora  was  noted 
in  4  cases,  and  dacryocystitis  in  3,  this  generally  being  one  of 
the  early  signs  of  the  disease.  In  those  cases  in  which  the 
nasal  obstruction  is  complete  the  relief  and  satisfaction  to  the 
patient  are  marked,  as  was  demonstrated  in  KanaveFs  own 
case,  where  complete  anosmia  was  demonstrated  by  Kahn  and 
obliteration  of  both  fossae  was  present,  wit^i  a  constant  puru- 
lent discharge.  Kanavel  does  not  believe  that  the  antrum 
of  Highmore  was  involved.  The  enlargement  was  so  great  as 
to  have  led  earlier  observers  to  diagnose  bilateral  osteomata. 
Under  complete  anesthesia  the  bony  deposits  on  both  sides 
were  chiseled  out,  giving  a  free  ingress  to  air.  After  some 
weeks  of  local  treatment  by  Boddinger,  the  nasal  discharge 


348  TUMORS    OF    THE    JAWS 

ceased,  and  the  patient  makes  no  complaint  except  that  he 
has  some  earache — whether  due  to  local  irritation  or  to  in- 
volvement of  nerves  in  bony  deposit  is  still  open  to  ques- 
tion. From  a  study,  cases  2,  13,  23,  26,  27,  and  28  might  also 
have  been  relieved  in  like  manner.  The  permanence  of  the 
relief  depends,  of  course,  upon  the  rapidity  of  growth.  In 
Kanavel's  case  the  bone  had  been  growing  for  ten  years, 
at  least;  seven  years  previously  he  had  complained  of 
dacryocystitis,  so  that  there  is  every  possibility  that  some 
years  may  elapse  before  a  second  operation  is  indicated. 

Other  operative  attempts  to  relieve  the  neuralgia,  prevent 
growth,  and  relieve  deformity  have  been  made  as  follows: 
Horsley  (case  2)  operated  to  determine  whether  the  branches 
of  the  middle  division  of  the  fifth  nerve  were  involved. 
An  excision  of  the  jaw  was  found  to  be  the  procedure  which 
offered  the  best  hope  of  relief,  but  this  the  patient  would  not 
consent  to.  The  right  upper  and  right  lower  jaws  had  been 
removed  five  years  previously  in  this  case. 

The  relationship  between  acromegaly  and  von  Reckling- 
hausen's  disease  cannot  be  stated  at  present.  Leontiasis 
ossea  certainly  preserves  its  clinical  individuality,  although 
it  cannot  yet  be  classified  as  having  a  clear  pathology. 


A  Case  of  Leontiasis  Ossea. — Reported  by  James  J. 
Cole,  and  observed  in  the  clinic  of  Kanavel  at  the  Post- 
graduate Hospital  in  Chicago : 

J.  W.  Male.  Age,  twenty-two  years.  Single.  Irish- 
American.  The  family  history  shows  the  presence  of  tuber- 
culosis, alcoholism,  and  a  probable  syphilis  in  relatives. 

The  present  illness  dates  back  to  the  age  of  two  and  a 
half  years,  when  he  had  his  first  attack.  His  speech  left 
him,  and  he  dragged  both  feet.  After  three  months  his 


LEONTIASIS    OSSEA  349 

speech  gradually  improved.  Unconsciousness  did  not  ac- 
company this  attack. 

When  he  was  four  years  old  he  had  his  first  convulsion, 
and  was  unconscious  for  four  hours.  The  defect  in  his 
speech  was  again  noticed,  and  he  dragged  both  feet  more 
than  ever;  the  right  arm  was  partially  paralyzed  also. 
From  this  time  convulsions  recurred  as  often  as  once  a 
month,  accompanied  by  unconsciousness,  up  to  the  time  he 
was  eleven  years  old,  but  since  then,  up  to  the  present  time, 
he  has  had  no  convulsions. 

When  the  patient  was  seven  years  old  a  small  hard  swell- 
ing was  noticed  under  the  right  eye,  then  similar  swellings 
appeared  on  the  lower  and  upper  maxillae  of  the  left  side. 
These  gradually  increased  in  size  up  to  the  time  of  his  en- 
trance into  the  hospital.  At  this  time  bilateral  exoph- 
thalmos  was  evident,  and  the  patient  stated  that  this  had 
become  marked,  especially  within  the  last  two  years. 

Pain  was  present  in  the  head, — more  so  over  the  frontal 
region, — and  this  pain  had  increased  in  severity  for  a  year 
previous  to  his  entrance  into  the  hospital.  For  three  years 
he  had  been  unable  to  breathe  through  his  nose,  owing  to  the 
encroachment  of  the  bony  masses  on  the  nasal  cavities. 
Difficulty  in  walking,  with  dragging  of  both  feet  and  partial 
paralysis  of  the  right  arm,  was  noticeable  at  the  time  he 
presented  himself  for  treatment. 

First  Operation. — Removal  of  the  excessive  growth  upon 
the  two  superior  maxilla?;  opening  of  the  nares;  enlarging 
the  orbits  so  as  to  relieve  the  pressure  upon  the  eyes.  An 
incision  was  made  along  the  right  edge  of  the  nose  and  below 
the  right  eyelid,  making  an  L-shaped  incision.  Through 
this,  with  a  chisel  and  hammer,  the  excessive  tissue  was  re- 
moved. It  was  found  to  be  of  great  hardness,  but  not  like 
that  of  ivory.  There  was  little  cancelous  bone.  The  ex- 
cessive bony  mass  was  removed,  bringing  the  contour  of  the 
face  down  to  its  normal  lines.  At  the  upper  edge  the  floor 


350 


TUMORS    OF   THE    JAWS 


Fig.  320. — Case  of  Kanavel  and  Cole:    1,  Before  first  operation ;    2,  after  first 
operation;     3,   before  second  operation;     4,  after  second  operation. 


LEONTIASIS   OSSEA  351 

of  the  orbit  was  removed  back  into  the  orbit  for  a  distance  of 
2 1/2  cm.,  which  seemed  to  remove  the  pressure  on  the  eyeball 
and  allow  it  to  sink  back  into  the  orbit.  Through  the  same 
incision, — the  nose  being  retracted  to  the  left, — with  a  chisel 
and  hammer,  an  opening  %  inch  in  diameter  was  made 
directly  through  the  bone  to  the  posterior  pharyngeal  vault. 
No  evidence  was  seen  of  mucous  membrane  or  of  the  nasal 
septum.  The  antra  were  apparently  obliterated.  The  bone, 
however,  was  not  of  the  hardness  noted  on  the  surface,  and 
was  removed  without  a  great  deal  of  difficulty,  which  may 
have  been  due  to  a  partial  cavity  further  back.  The  nose 
was  then  replaced  in  position,  the  skin  sutured  with  a  fine 
subcutaneous  stitch,  and  packing  placed  in  the  nose. 

On  the  left  side  the  incision  was  made  parallel  with  the 
edge  of  the  normal  position  of  the  superior  maxilla.  Through 
this  incision  the  excessive  bone  was  chiseled  away  to  bring 
this  side  also  down  to  the  normal  outlines,  and  the  osseous 
tissue  underneath  the  eye  in  the  orbit  was  removed  in  like 
manner  to  that  on  the  right,  when  the  eye  assumed  its  normal 
position. 

The  wounds  healed  by  primary  intention,  and  the  patient 
was  well  satisfied  with  the  result  upon  his  nose  and  the 
appearance  of  the  face.  It  is  now  a  year  and  a  half  since 
the  operation,  and  there  has  been  no  return  of  the  eye  symp- 
toms. 

Report  of  Eye-findings  Before  and  After  Operation   (By  G. 

F.  Suker) 

(a)  Bilateral  proptosis,  more  marked  on  right  than  left. 

(6)  Marked  turgescence  of  the  conjunctival  vessels  of  both  eyes. 

(c)  Reduced  sensibility  in  each  cornea. 

(d)  Suppurative  dacryocystitis  on  the  right  side. 

(e)  Marked  enlargement  of  fundus  vessels  in  each  eye. 
(/)    Moderate  dilatation  of  each  pupil. 

(g)   Moderate  choked  disc  in  each  eye — more  in  right. 
(h)  Marked  encroachment  upon  size  of  orbit,  particularly  right. 
(i)    Increased  palpebral  aperture  in  each  side,  due  to  protrusion  of 
globe. 


352  TUMORS   OF   THE   JAWS 

(j)   Pupillary  reactions  not  prompt  and  limited  in  extent;    same  in 

both  eyes, 
(fc)  Slight  limitation  in  excursion  of  globes. 

Subsequent  to  the  operation  there  was: 

(a)  Recession  of  proptosis. 

(6)  Return  of  normal  palpebral  aperture. 

(c)  Cessation  of  conjunctival  vessel  enlargement. 

(d)  Diminution  of  choked  disc. 

(e)  Recession  in  the  enlargement  of  the  fundus  vessels. 
(/)    Reappearance  of  corneal  sensation. 

(g)  Apparent  normal  ocular  excursions. 
(h)  Other  conditions  remained  stationary. 

Second  Operation. — Four  weeks  after  the  first  operation 
an  incision  was  made  underneath  the  angle  of  the  jaw,  the 
skin  retracted,  and  the  excessive  bony  tissue  chiseled  away, 
bringing  this  side  of  the  face  down  to  the  normal  outlines. 
Some  doubt  was  felt  as  to  whether  this  would  relieve  the 
pain,  since  we  could  not  determine  in  what  nerve  it  had  its 
seat.  It  did,  however,  remove  the  unsightliness  of  that 
side,  and  the  immediate  result,  at  least,  was  to  remove  the 
pain.  At  the  present  time,  however,  he  complains  of  some 
slight  pain  on  that  side,  but  not  so  marked  as  before  operation. 
Third  Operation. — About  nine  months  after  the  first 
operation  the  patient  began  to  complain  of  headache,  which 
had  been  increasing  in  severity  for  two  months.  The  mother 
also  felt  that  the  patient  was  becoming  more  irritable  and 
more  difficult  to  control.  Following  this  complaint  the 
patient  was  examined,  and  it  was  deemed  advisable  to  do  a 
decompression  operation.  Accordingly,  a  semilunar  incision 
was  made  on  the  left  side,  where  an  excessive  growth  of 
bone  just  above  the  ear  appeared  to  be.  An  incision  was 
made,  2^  inches  in  diameter,  and  the  flap  turned  downward, 
including  a  portion  of  the  temporal  fascia  and  muscle.  From 
this  area,  by  means  of  a  trephine  and  later  with  a  chisel,  a 
large  area  of  the  cranial  bones  was  removed.  In  the  anterior 
portion  the  bone  was  found  to  be  about  one-third  of  an  inch 
in  thickness;  at  the  posterior  end  of  the  area,  however,  the 


LEONTIASIS   OSSEA  353 

bone  was  nearly  one  inch  in  thickness.  The  dura  was  not 
opened,  and,  after  removing  the  bone,  the  muscles  and  skin 
were  sutured  in  place  by  the  usual  methods. 

Following  the  operation  the  patient  made  an  uneventful 
recovery.  His  headache  ceased,  and  his  mother  reported 
that  he  was  slightly  less  inclined  to  his  uncontrollable  at- 
tacks, although  in  this  regard  the  result  was  not  so  marked 
as  in  the  case  of  headaches,  of  which  he  has  not  complained 
since. 

In  this  relation  it  was  noted  at  the  operation  that  there 
did  not  seem  to  be  excessive  tension  underneath  the  dura. 

At  the  present  writing  this  patient  is  beginning  again  to 
show  obstruction  to  the  nasal  breathing,  and  it  is  probable 
that  further  surgical  interference  will  be  necessary  to  remedy 
this  condition. 


23 


CHAPTER  IX 
PROSTHESIS 

CONTENTS  OF  CHAPTER:  General  observations. — Methods  of  prosthesis  used 
by — Hahl,  of  Berlin;  Fritzsche;  Schroder;  Boennecker;  Partsch;  Hoff- 
mann and  Kayser;  Garre;  Berndt;  Bardenheuer;  Wolfle;  Wildt; 
Konig;  Magnuson;  Sykoff ;  Krause. — Conclusions  regarding  prosthesis. 

GENERAL  OBSERVATIONS 

FoLLowing  operations  upon  the  jaws  for  the  removal 
of  a  part  or  the  whole  of  the  upper  or  lower  maxilla  it  is  often 
wise  to  introduce  some  appliance  that  will  fill  the  gap  made 
in  the  jaw. 

The  details  of  this  fitting  of  apparatus — the  prosthesis- 
have,  in  this  country,  been  left  very  largely  to  the  dental 
surgeon.  The  operating  surgeon  is  not  usually  informed  as 
to  the  different  kinds  of  prosthetic  apparatus  available.  It 
is  in  order  that  the  operating  surgeon  may  somewhat  under- 
stand the  principles  underlying  the  choice,  manufacture,  and 
application  of  prosthetic  apparatus  that  this  chapter  is  intro- 
duced here. 

The  surgeon  should  be  familiar  with  the  indications  for 
and  against  the  use  of  an  immediate  prosthesis,  that  is,  at 
the  conclusion  of  the  operative  removal  of  the  diseased  bone. 
The  surgeon  should  be  informed  as  to  why  it  is  better,  under 
some  circumstances,  to  postpone  the  use  of  prosthetic  ap- 
pliances until  the  wound  is  completely  healed  (secondary 
prosthesis). 

In  any  given  case  the  following  questions  arise : 

Is  some  form  of  prosthesis  desirable? 

354 


PROSTHESIS  355 

Shall  it  be  immediate  or  secondary? 

If  immediate,  what  device  will  meet  the  requirement  in 
the  particular  case? 

If  secondary,  when  shall  it  be  applied  and  what  apparatus 
will  be  best  under  the  circumstances? 

Will  the  particular  individual  be  able  to  tolerate  a  foreign 
apparatus  in  the  mouth  constantly?  ' 

Will  the  mouth  parts  react  too  violently  against  the  intro- 
duction of  a  foreign  body  into  the  tissues? 

All  these  questions  must  be /considered  if  the  operating 
surgeon  would  deal  successfully 'with  the  prosthesis  following 
operation  upon  the  jaws.  THere  are  many  cases  in  which 
apparatus  will  not  be  tolerated — cases  in  which  apparatus 
will  not  be  employed.  The  post-operative  deformity  in 
certain  cases  will  be  very  slight,  and  will  not  need  prosthetic 
apparatus. 

Familiarity  with  the  forms  of  prosthesis  available  will 
assist  the  surgeon  in  adjusting  apparatus  to  the  wound 
resulting  from  certain  operative  technic. 

Prosthesis,  when  employe^,  is  intended — (1)  To  mini- 
mize deformity  occasioned  by  loss  of  bone  and  soft  parts — 
i.  e.,  it  is  used  for  cosmetic  reasons;  (2)  to  preserve  the  aline- 
ment  of  the  teeth,  so  that  chewing  or  biting  may  be  employed 
in  the  mastication  of  food — i.  e.,  it  is  used"  for  practical 
reasons. 

Following  resection  of  the  lower  jaw,  the  anterior  sawn 
edges  of  the  jaw  tend  to  become  approximated.  After  re- 
moval of  the  symphysis,  for  instance,  not  only  is  the  chin 
less  prominent  and  rounded,  but  it  is  more  pointed;  the 
two  halves  of  the  jaws  tend  to  fall  together.  (See  Figs.  51, 
52,  53,  54,  Chapter  II.) 


356 


TUMORS    OF    THE    JAWS 


Immediately  after  operation  for  the  removal  of  the  sym- 
physis  and  considerable  bone  extending  back  on  each  side  to 
the  angle  of  the  jaw,  the  attempt  to  bring  the  bone  remaining 
together  so  constricts  the  floor  of  the  mouth  and  the  parts 
posteriorly  at  the  base  of  the  tongue  that  respiration  may  be 
interfered  with.  Some  apparatus  is  needed  to  keep  these 
inferior  maxillary  bones  apart  and  in  their  normal  relations. 


—  5 


Fig.  321. — Immediate  prosthesis  (O.  Martin)  for  exarticulation  of  one- 
half  of  the  lower  jaw.  Apparatus  is  split  to  exhibit  the  system  of  channels 
for  irrigation,  R,  and  the  rubber  tube  for  introducing  irrigation  fluid,  S. 


If  one  half  of  the  lower  jaw  is  removed,  the  remaining 
half  of  the  bone  is  approximated  to  the  midline  by  the  un- 
opposed contraction  of  the  internal  pterygoid  muscle  of  that 
same  side.  Not  only  does  the  primary  pull  of  the  pterygoid 
displace  the  bony  stumps,  but  the  subsequent  cicatricial 
contraction  adds  its  quota  to  the  permanent  deformity. 


PROSTHESIS 


357 


The  use  of  an  immediate  prosthesis — i.  e.,  introduced 
into  the  mouth  at  the  time  of  the  operation,  which  may  be 
replaced  by  a  more  permanent  and  durable  splint  at  a  later 
period — is  described  by  Martin-Oilier,  of  Lyons,  France. 

The  use  of  a  prosthesis  after  the  wounds  are  healed  is 
advocated  by  Sauer-von  Tropmann,  of  Berlin. 

There  are,  of  course,  many  modifications  of  these  two 


Fig.  322. — If  two  or  three  teeth  remain  in  the  jaw,  it  is  possible  to  hold 
the  two  halves  of  the  jaw  apart  by  a  heavy  wire  which  is  fastened  about  the 
teeth  or  fastened  to  a  tooth-cap  (Hahl). 


fundamentally  different  methods.  The  more  important 
modifications  will  be  mentioned. 

Oilier  and  Martin  recommend  the  replacing  of  the  defect 
at  the  time  of  the  operation  by  an  apparatus  made  of  hard 
rubber,  fixed  in  situ,  and  superseded  by  a  smaller  removable 
apparatus  after  healing  has  taken  place. 

In  certain  cases  this  apparatus  may  loosen  teeth.     The 


358  TUMORS    OF   THE   JAWS 

attachments  may  have  to  be  changed,  and  caps  may  have  to 
be  used. 

The  apparatus  for  the  lower  jaw,  in  cases  of  complete 
removal  of  one-half  of  the  jaw,  fits  into  the  glenoid  cavity 
directly.  It  is  united  to  the  bony  stump  by  suture.  It  is 
cleansed  by  irrigation  through  many  channels  (Fig.  321). 

Bergmann  and  Sauer  apply  prosthesis  after  healing  is 


Fig.  323. — Prosthesis  used  for  replacing  the  symphysis.  Note  the 
elliptic  plate  to  hold  forward  the  chin.  Note  the  metallic  pins  which,  pene- 
trating the  cut  surfaces  of  the  two  rami,  hold  the  splint  in  firm  position  (Hahl 
and  Witzel). 

complete.     A  cast  is  taken  by  a  dentist  before  operation,  so 
as  to  have  a  guide  as  to  the  part  to  be  replaced. 

The  splint  rests  in  the  mouth  and  is  uncovered.  The 
risk  of  infection  of  the  buccal  cavity  is  comparatively  slight 
if  the  apparatus  is  kept  clean.  The  apparatus  should  be 
cleaned  and  replaced  immediately.  If  it  is  left  out  long  it 
is  difficult  to  replace  it. 


PROSTHESIS 


359 


METHODS  OF  PROSTHESIS 

Hahl  reports  the  methods  of  prosthesis  employed  in 
Berlin  from  1887  to  1899  in  the  group  of  45  lower  and  81 
upper  jaw  resections.  The  methods  of  use  of  prosthesis  in 
these  cases  may  be  grouped  as  follows: 

First  Group:  Those  cases  in  which  the  chin  or  symphysis 
is  removed.  A  wire  of  gold,  aluminum,  bronze,  or  nickeled 
steel  is  set  in  the  place  of  the  resected  bone.  If  there  are 


Fig.  324. — If  there  are  teeth  only  in  one-half  of  the  remaining  jaw,  then  the 
above  method  may  be  used  (Hahl). 


teeth,  the  wire  is  wound  about  them  to  secure  support  (Fig. 
322) .  If  there  are  no  teeth,  then  Boennecken's  wire  bridge,  em- 
bracing the  stumps  of  the  teeth,  is  used,  or  a  spindle-shaped 
metal  body  to  support  the  lower  lip,  with  two  sharp  ends 
which  may  be  pushed  into  the  bone  and  fastened  by  ligature, 
is  used.  (See  Fig.  323.)  As  soon  as  healing  is  completed  the 
wire  splint  is  removed  and  a  broad,  hard-rubber  splint  with 


360 


TUMORS   OF   THE   JAWS 


ring-like  processes  is  attached  to  the  stumps,  and  is  held 
by  a  special  spring  to  an  upper  plate. 

Second  Group:  Those  cases  in  which  a  partial  resection  in 
continuity  was  done  of  part  of  the  lower  jaw.  Into  the  gap 
thus  formed  was  placed  a  piece  of  gold  or  aluminum  bronze, 
about  the  size  of  a  lead-pencil,  the  pointed  ends  becoming 
fastened  directly  into  the  spongiosum  of  the  stumps  of  the 
bone.  This  usually  healed  in  situ.  (See  Figs.  323  and  327.) 


Fig.  325. — Apparatus  intended  to  fill  the  gap  made  by  removal  of  the  symph ysis 
of  the  lower  jaw  (after  Boennecken). 


Third  Group:  Those  cases  from  whom  the  whole  half  of 
the  jaw  was  removed.  The  slanting  splint  of  Sauer  was  used 
here,  in  order  to  keep  the  jaw  remaining  over  on  the  sound 
side.  This  splint  was  put  in  place  at  the  time  of  the  opera- 
tion. 

Fritzsche*  suggests  a  tin  splint,  imitating  as  closely  as 
possible  the  shape  of  the  removed  part  of  the  jaw.  (See  Fig. 

*  Deut.  Zeit.  f.  Chir.,  1901,  vol.  Ixi,  pp.  560-576. 


PROSTHESIS 


361 


331.)  This  is  inserted  at  the  original  operation,  and  sewed 
in  place  by  splint  carriers,  which  are  wired  to  the  jaw  frag- 
ments. The  splint,  which  is  cast  beforehand  from  a  plaster 
mold,  can  be  removed  at  each  dressing  and  cleaned.  When 
the  jaw  is  exarticulated,  a  condyloid  process  is  made  on  one 
end  of  the  splint,  and  this  fills  the  glenoid  fossa.  After  three 


Fig.  326.— An  upper  plate  for  a  defect  in  the  upper  jaw,  attached  to  the  lower 
hard-rubber  plate  by  means  of  springs  (Boennecken). 

or  four  weeks  this  splint  is  replaced  by  a  permanent  pros- 
thesis of  hard  rubber,  molded  in  the  same  form,  which  can 
be  easily  removed  and  reinserted  by  the  patient. 

Schroder  improved  somewhat  upon  the  Fritzsche  splint. 

In  resections  of  the  toothless  lower  jaw  associated  with 
separation  in  continuity,  in  cases  in  which  there  is  no  ex- 


362  TUMORS    OF   THE   JAWS 

articulation,*  Boennecken  recommends  a  metal  splint  with 
two  ring-like  processes  on  each  side  (Fig.  325).  These  em- 
brace the  stumps  of  the  jaw.  The  stumps  and  the  rings  are 
bored  through  on  each  side,  and  the  splint  is  secured  with 
screws.  After  complete  healing  the  splint  is  removed  and 
the  defect  filled  with  a  permanent  prosthesis.  This  method 
was  much  improved  by  Hahl. 


Fig.  327. — An  aluminum  bronze  plate  having  forked  teeth  to  penetrate  the 
bone  on  either  side  of  the  gap  made  by  the  excised  bone  (Hahl). 

Partschf  employs  small  perforated  strips  of  metal,  se- 
cured to  the  jaw-stumps  by  wire,  as  an  immediate  appliance 
to  prevent  contractions  and  displacements  during  healing, 
which  is  not  at  all  impeded  by  their  presence.  When  the 
wound  closes,  they  are  removed  and  replaced  by  a  permanent 

*  Verhandl.  d.  Deut.  odont.  Gesellsch.,  vol.  iv. 
t  Langenbeck:  Arch.  f.  klin.  Chir.,  vol.  Iv,  p.  746. 


PROSTHESIS 


363 


prosthesis,  secured  in  position  by  hard-rubber  clamps  fitting 
over  appropriate  metal  crowns  applied  to  the  teeth  (Fig. 
329). 

It  is  important  to  suture  the  mucous  membrane  over 


Fig.  328. — Bardenheuer's  method  of  autoplasty  to  fill  a  defect  in  continuity 

of  the  jaw. 


the  splint  with  great  care,  in  order  to  shut  off  the  wound  as 
far  as  possible  from  the  oral  cavity. 

Hoffmann  and  Kayser*  believe  wire  the  best  suture 
material  for  plastic  repair  of  the  lower  jaw,  and  find  that  it 
heals  in  well,  even  in  granulating  wounds.  They  also  employ 

*  Centralbl.  f.  Chir.,  1904,  vol.  xxvii,  p.  1145. 


364 


TUMORS    OF    THE    JAWS 


Fig.  329. — The  symphysis  is  gone.     A  method  for  bridging  the  defect 

(Partsch). 


Fig.  330. — An  apparatus  which  is  wired  to  the  jaw-stumps.  Used  for 
symphysis  defects.  Perforated  with  holes  for  purpose  of  irrigation  (Stoppany, 
Schlatter). 


PROSTHESIS  365 

silver  wire  as  a  heteroplastic  material,  to  fill  in  larger  defects, 
and  think  such  use  better  than  autoplasty.  Hoffmann  de- 
scribes a  plastic  operation  in  a  thirteen-year-old  boy  for 
extensive  necrosis  which  had  destroyed  the  left  angle  of  the 
lower  jaw  and  the  ascending  ramus  as  far  as  the  articular 
process.  After  removal  of  all  carious  material  the  upper 
and  lower  teeth  were  2  cm.  apart.  A  wire  was  then  passed 
from  without  inward  through  a  drill-hole  in  the  articular 


mP-^^^^r 


Fig.  331. — Parts  of  a  splint  to  be  constructed  by  fastening  together  with  pins, 
to  occupy  the  place  of  a  resected  lower  jaw  (Fritzsche). 


process  of  the  lower  jaw,  and  the  inner  end  carried  within 
outward  through  a  drill-hole  in  the  stump  of  the  horizontal 
ramus,  and  twisted  writh  the  other  free  end.  This  wire 
prosthesis,  bent  so  as  to  reconstruct  an  angle  for  the  jaw, 
soon  became  covered  with  granulations,  and  healed  firmly 
in  place,  with  excellent  restoration  of  function.  By  this 
method  he  was  able  to  restore  more  than  half  the  lower  jaw. 
Garre  uses  and  buries  a  thick,  properly  shaped  piano 


366  TUMORS    OF   THE   JAWS 

wire,  fastened  to  one  end  of  the  divided  jaw;  the  bent  end  or 
loop  end  articulates  well  without  too  great  irritation. 

Berndt*  believes  metal  unsuitable  for  bone  plastics,  and 


Fig.  332. — Sauer's  vertical  plate  attached  to  a  permanent  lower  jaw  splint. 
The  vertical  plate  prevents  slipping  of  the  apparatus. 

thinks  celluloid  is  the  best  heteroplastic  material,  on  account 
of  its  sterilizability  and  low  specific  gravity.  He  uses  the 
common  celluloid  ring  employed  for  pessaries,  which  is 


Fig.  333. — Martin's  permanent  prosthesis,  to  be  applied  after  the  removal 
of  the  temporary  apparatus. 

sterilized  and  made  flexible  by  boiling,  and  can  readily  be 
bent  into  the  form  of  the  resected  half  of  the  jaw.  This  is 
placed  in  the  wound  and  secured  by  packing,  with  secondary 

*  Langenbeck:  Arch.  f.  klin.  Chir.,  vol.  Ivi,  p.  208. 


PROSTHESIS 


367 


suture  after  a  few  days.  He  reports  4  cases  in  which  this 
method  was  applied,  with  excellent  result:  the  prosthesis 
healed  in  place,  though  generally  with  a  fistula  for  a  time. 
Essential  to  healing  is  closure  of  communication  between 
wound  and  buccal  cavity;  if  this  is  not  attained  by  primary 
suture  of  the  mucous  membrane,  it  is  better  to  delay  inser- 
tion of  the  prosthesis  until  granulation  has  begun. 


Fig.  334. — Oilier  Martin's  primary  rubber  apparatus  for  use  after  resection 
of  the  upper  jaw.  This  is  secured  in  position  by  screws  and  clamps  and  a 
lateral  spring. 

Bardenheuer*  employs  an  osteoplastic  flap  from  the 
forehead  in  certain  suitable  cases  to  fill  in  a  bone-gap. 

Wolflef  uses  also  an  autoplastic  flap,  but  he  employs  the 
skin  of  the  neck  and  a  piece  of  the  clavicle. 

WildtJ  describes  a  method  of  Bardenheuer  for  replacing 

*  Langenbeck:  Arch.  f.  klin.  Chir.,  1892,  vol.  xliv,  p.  604;  vol.  xliii,  p.  32. 
t  Centralbl.  f.  Chir.,  1892,  p.  80. 
I  Ibid.,  1896,  No.  50,  p.  1177. 


368 


TUMORS    OF    THE    JAWS 


a  unilateral  defect  of  the  lower  jaw.  He  removes  a  rec- 
tangular piece  of  bone,  covered  with  periosteum,  connected 
below  and  behind  with  the  musculature,  from  the  horizontal 
ramus  of  the  jaw  of  the  same  side.  This  piece  of  attached 


Fig.  335. — In  case  of  removal  of  upper  jaw,  a  vertical  plate  of  sheet 
tin,  covered  by  hard  black  rubber  attached  to  a  palate  and  horizontal  plate 
bearing  teeth,  is  used.  This  is  held  in  position  by  a  spring  connection  with 
clasps  about  the  teeth  of  the  lower  jaw  (Hahl). 


bone  is  pushed  backward  into  the  defect  and  secured  by  wires 
passed  through  the  holes  previously  drilled.  (See  Fig.  328.) 
Others  have  used  a  transplanted,  resected  bit  of  rib  to 
replace  the  bony  defect  following  resection  of  the  jaw.  In 
one  instance  the  rib  was  temporarily  turned  up  in  the  skin- 
flap,  and  subsequently  transferred  to  the  jaw  with  a  flap  of 


PROSTHESIS 


369 


skin.  In  another  instance  a  transplantation  of  periosteally 
covered  resected  rib  was  done. 

Konig  has  successfully  employed  an  ivory  splint. 

Magnuson*  has  demonstrated  that  ivory  will  heal  kindly 
in  situ,  and  that  it  will  be  replaced  by  bone. 


Fig.  336. — Shows  a  plaster  cast  of  the  defect  in  the  upper  jaw,  for  which  the 
apparatus  (Fig.  335)  was  devised  (Hahl). 

Sykofff  has  taken  bone  in  a  similar  fashion  from  the  right 
half  of  the  jaw  to  fill  a  defect  in  the  chin  or  symphysis. 

KrauseJ  employs  skin-muscle-periosteum-bone  flaps, 
taken  from  the  lower  border  of  the  intact  half  of  the  lower 
jaw,  and  operates  in  two  sittings:  at  the  first  he  introduces 
a  piece  of  ivory  into  the  defect,  the  actual  plastic  work  being 
done  at  the  second  sitting,  in  order  to  have  reliable  aseptic 
conditions. 

*  University  of  Penn.  Med.  Bull.,  1908,  vol.  xxi.  p.  103. 
f  Centralbl.  f.  Chir.,  1900,  No.  35,  p.  881. 
I  Ibid.,  1904,  Xo.  25..  p.  767. 
24 


370 


TUMORS   OF   THE   JAWS 


Fig.  337. — Permanent  apparatus    for  upper   jaw    resection     (see  Fig.  338) 

(after  Hani). 


Caoutchouc 


Metal 


Metal  •-' 


''•    Caoutchouc 


Caoutchouc 


Fig.  338. — Permanent  apparatus  for  resection  of  the  upper  jaw;  orbital 
plate  removed.  The  plate  is  made  of  aluminum  bronze;  the  projecting  knob 
is  hard  rubber  covering  sheet  tin.  This  is  attached  by  lateral  springs  to  the 
teeth  of  the  lower  jaw  (after  Hahl). 


PROSTHESIS 


371 


Fig.  339. — Sarcoma  of  left  lower  jaw.     Removed  by  resection   of  the  left 
lower  jaw.     Prosthesis  permanent  (von  Eiselsberg). 


Fig.  340.— Same  as  Fig.  339. 


372 


TUMORS    OF    THE    JAWS 


Fig.  341. — Man,  sixty-four  years  old.  Carcinoma  of  lower  jaw.  Resec- 
tion. Prosthesis.  No  recurrence  after  one  year  and  a  half  (Pichler  and 
Ranzi). 


Fig.  342.— Same  as  Fig.  341  (Pichler  and  Ranzi,). 


PROSTHESIS 


373 


CONCLUSIONS  REGARDING  PROSTHESIS 
If  the  defect  remaining  after  operation  upon  the  lower  or 
upper  jaws  causes  deformity  or  loss  of  function,  this  resulting 
deformity  or  loss  of  function  should  be  overcome.  Some 
form  of  prosthetic  appliance  should  be  employed.  The 
temporary  prosthesis  should  be  followed  by  a  permanent 
appliance.  The  permanent  prosthesis  ordinarily  may  be 
applied  about  one  month  or  six  weeks  after  the  operation. 


Fig.  343. — Carcinoma  of  floor  of  mouth  and  resection  of  the  symphysis. 

Prosthesis  (Konig). 

The  exact  form  of  the  prosthetic  appliance  will  necessarily 
depend  upon  the  conditions  in  each  case.  The  material  of 
which  the  temporary  or  permanent  apparatus  is  made  has 
been  a  matter  of  experiment.  Hard  rubber,  magnesium, 
celluloid,  fresh  animal  bone,  old  sterile  bone,  ivory,  silver, 
aluminum,  and  other  metals  have  all  been  tried.  The 
simplest  apparatus  and  the  least  irritating  is  best.  Ivory 
and  a  small  strong  wire  seem  to  meet  best  the  requirements 
of  a  permanent  and  temporary  prosthesis  respectively. 


374 


TUMORS    OF   THE    JAWS 


Fig.  344. — Prosthetic  appliance  used  in  case  shown  in  Fig.  343.  P,  the 
part  under  the  tongue,  and  attached  by  h  to  sound  teeth  in  the  right  side; 
2,  artificial  teeth  in  plate;  G,  the  part  articulating  with  the  glenoid  fossa,  and 
forming  the  ascending  ramus  of  the  jaw  (Konig). 


Fig.  345. — Removal  of  one-half  the  lower  jaw  on  the  left  side, 
appliance  in  place  (case  of  Konig). 


Prosthetic 


INDEX  OF  NAMES 


ALBARRAN,  177,  222 
Albert,  322 
Allen,  92 
Andrews,  174 

BALCH,  55,  56,  57 

Bannister,  32,  33 

Bardenheuer,  363,  367 

Barrie,  197,  202,  208,  209,  211,  212 

Batzaroff,  42,  55,  102,  242,  246,  260 

Bauchet,  141,  144 

Bayer,  55,  283 

Beach,  61,  69 

Beck,  334,  335,  336,  337,  338 

Becker,  197 

Beckmann,  283 

Behm,  42,  55,  242,  282 

Bellocq,  295 

Bergmann,  115,  305,  358 

Berjor,  146 

Berndt,  366 

Bigelow,  158 

Billroth,  115,  322 

Birnbaum,  42,  55,  242,  260 

Bland-Sutton,  162,  234,  239 

Blauel,  140,  143,  145,  323 

Bloodgood,  17,  18,  20,  21,  22,  29,  30, 
38,  39,  44,  52,  53,  54,  59,  65,  94, 123, 
124,  126,  136,  177,  185,  186,  188, 
189,  197,  198,  199,  208,  209,  214, 
215,  253 

Bockenheimer,  300 

Boddinger,  347 

Boennecken,  359,  360,  361 

Bolles,  239 

Bordenaave,  144 


Borhaupt,  160 

Borst,  197 

Braun,  260 

Broca,  30,  143,  209,  239 

Brown,  121,  156,  212,  237,  238 

Bryant,  83,  88,  292 

Butlin,  83,  110,  114,  117,  118,  257 

CABOT,  236 
Chibret,  195,  197 
Coenen,  326,  327 
Cole,  348,  350 
Coley,  58,  60,  65 
Comisso,  83,  283 
Conant,  279 
Cooper,  345 
Cousins,  217,  220,  221 
Crile,  290,  293,  295 
Cusack,  117 

DARNELL,  250 

Dauphin,  41 

Depaye,  304 

Dieffenbach,  297 

Donogany,  250 

Dudley,  64,  80,  81,  82,  208,  209,  213, 

249,  259,  260,  261,  266 
Dupuytren,  117,  198 

EBERTH,  293 
Eckert,  156 
Edes,  346 
Eiselsberg,  371 
Eisenmenger,  322,  325 
Elliot,  267 


375 


376 


INDEX    OF    NAMES 


Enderlen,  304 
Estlander,  41 
Eve,  118,  239 

FERGUSON,  296,  297 
Friedman,  323 
Fritzsche,  360,  365 
Fuchs,  261,  263 

GARRE,  304,  365 

Gosselin,  295 

Greenough,  241,  278 

Gruet,  24 

Gunn,  345, 

Gunzert,  2^38 

Gussenbauer,  261,  264,  322,  323 

Gussenbaum,  98,  99 

HAASLER,  35 

Hahl,  357,  358,  359,  362,  368,  369,  370 

Halsted,  59,  185,  188,  189,  214,  215 

Harrington,  248 

Heath,  31,  117,  141,  142,  143,  144, 

145,  148,  149,  150,  153,  222,  239, 

321 

Heisler,  239 
Hertle,  304,  305 
Hildebrand,  195,  196 
Kingston,  146,  147,  148 

offmann,  305.  330.  363,  365 

ofmokl,  283 

Horsley,  342,  343,  345,  347,  348 
Howslip,  346 

JACOBSON,  325 

KAHN,  347 

Kanavel,  333,  341,  342,  344,  345,  346, 

347,  348,  350 
Kaposi,  103,  117,  255 
Kayser,  363 
Keen,  298,  343,  345 
Killian,  245,  314 
Kocher,  303,  304 


Konig,  41,  84,  86,  101,  103,  108,  113, 
115,  136,  139,  235,  261,  263,  264, 
301,  369,  373,  374 

Krause,  193,  194,  196,  197,  369 

Kritz,  141 

Kronlein,  102,  260,  263,  283 

Kuhlo,  197 

Kuhn,  305 

Kuster,  88,  91,  99,  102,  142,  260,  283 

Kuttner,  318 

LANGENBECK,  330,  362,  366,  367 

Larabee,  326 

Latham,  171,  173,  176 

Lawson,  150 

Lesser,  293 

Levi,  65 

Liebold,  323 

Lipps,  293 

Liston,  30,  31,  142,  143 

Lothrop,  281 

Lucke,  117 

Lund,  54 

Luther,  65 

MADELUNG,  292 

Magitot,  198 

Magnuson,  369 

Malassez,  172, 173,  197,  207,  208,  21 

228 

Maljutin,  250 
Marburg,  322 
Marshall,  163,  164,  165,  166,  167,  168, 

169,  170,  171,  172,  173,  174,  175,. 

176 
Martens,  42,  55,  84,  86,  87,  88,  91,  99, 

100,  101,  103,  106,  113,  114,  139, 

197,  235,  242,  245,  257,  260,  261, 

282,  283,  291 
Martin,  356,  366,  367 
Matas,  134,  294 
McCaw,  324 
McCurdy,  24,  25,  27 
Mears,  119 
Meller,  240,  281 


INDEX   OF   NAMES 


377 


Menzel,  144,  155 
Michelson,  322 
Mikulicz,  74,  212,  251,  322 
Mixter,  92,  93,  94,  266 
Moore,  149 
Morestin,  282 
Mosetig-Moorhof,  234 

NELATON,  58 
Nimmier,  140 
Moves,  175 
Nussbaum,  295 

OHLEMANN,  260,  283 
Oliver,  197 
Oilier,  357,  367 

Onodi,  230,  231,  313,  315,  316,  317, 
318 

PAGET,  198,  319,  325,  329 

Partsch,  26,  220,  226,  227,  232,  362, 

364 

Payr,  304 
Perthes,  23,  26,  30,  34,  45,  138,  139, 

141,  143,  145,  151,  152,  155,  156, 

157,  223,  226,  229,  231,  232,  233, 

234,  283 

Petzold,  260,  283 
Pilcher,  372 
Pincus,  197 
Pirogoff,  292 
Piscocek,  141 

Porter,  79,  84,  114,  116,  150 
Prince,  344,  346 
Putnam,  344,  345,  346 

RABE,  87,  88,  90,  91,  283,  295 
Ranji,  372 
Reyher,  292 
Ribel,  346 

Richardson,  134.  281 
Riedel,  247 
Riese,  292 
Rigaud,  144 


Rogers,  187,  202,  213 
Rose,  292,  295 
Rosenbach,  295 

SALTER,  38 

Sattler,  343,  345,  347 

Sauer,  357,  358,  360,  366 

Scannell,  281 

Schimmelbusch,  293 

Schlatter,  255,  283,  292,  364 

Schmidt,  42,  55,  146,  242 

Schoenborn,  293 

Schroder,  361 

Schulz,  142,  283 

Schutzenberger,  344 

Schwenn,  250 

Scudder,  278,  280 

Senger,  293 

Senn,  140, 

Simmons,  334,  339,  341 

Sirantoine,  197 

Smith,  324 

Southam,  158 

Stack,  345 

Starr,  339,  344 

Steele,  88,  90 

Steensland,  190,  191,  192,  196 

Stein,  42,  55,  115,  240,  242,  260,  263, 

282 

Stoppany,  364 
Streissler,  304,  305 
Suker,  351 

Sutton,  162,  234,  239 
Sykoff,  369 

THOMPSON,  151 

Tomes,  239 

Trendelenburg,  108,  252,  295 

Treves,  322,  323 

Tropmann,  357 

Trout  man,  250 

VERNEUIL,  295 
Vidal,  153 


378 


INDEX    OF    NAMES 


Virchow,  41,  140,  333 

Vitaul,  323 

Volkmann,  67,  157,  322,  325,  328 

Von  Bergmann,  115,  305,  358 

WARREN,  67,  108,  182,  201,  241 
Wassermann,  38 
Webber,  118,  296 
Westmacott,  158,  159,  160 
Whitney,  19,  20,  21,  46,  55,  62,  67,  70, 


Wildt,  367 
Williams,  42 
Winiwarter,  260,  283 
Witzel,  233,  358 
Wolfle,  367 
Wood,  326,  328 
Wrany,  344 
Wright,  62,  70,  149 

ZIEGLER,  333 


76,  85,  96,  122,  130,  132,  178,  179,       Zimmerman,  292 
184,  218,  331  Zuckerkandl,  142 


INDEX 


ABSCESS,  alveolar  epulis  and,  differ- 
entiation, 35 

Accessory  sinuses,  carcinoma  of,  250 

Actinomycosis,  epulis  and,  differen- 
tiation, 35 

Adamantine   epithelioma,    173.     See 
also  Epithelioma,  adamantine 

Adamantinoma,  175.     See  also  Epi- 
thelioma, adamantine 

Adenocarcinoma,  175.     See  also  Epi- 
thelioma, adamantine 

Adenoma  of  palate,  325 

Adenosarcoma,  175.     See  also  Epithe- 
lioma, adamantine 

Aluminum  bronze  plate  with  forked 

teeth,  362 
wire  prosthesis,  359 

Alveolar  border,  170 

carcinoma  of,  248 
osteoma,  158 

periostitis,  sarcoma   and,  differen- 
tiation, 79 

Alveolo-dental  periosteum,  171 

Alveolus,  normal,  159 

Ameloblastic  layer  of  teeth,  169 

Anatomy  of  sinuses  of  nose,  313 

Anesthesia,  290 

by  nasopharyngeal  tubage,  290,  295 
morphin  before,  289 

Angiosarcoma  of  lower  jaw,  inoper- 
able case,  129 

Anosmia  in  leontiasis  ossea,  347 

Antrum,  carcinoma  of,  250 

case,  241,  242,  253 
cmpyema  of,  in  sarcoma  and,  74, 
78 


Antrum,  growths  starting  from,  gain- 
ing access  to,  97 
osteoma  of,  156 
sarcoma  in,  treatment,  138 

Aspiration    pneumonia    after    opera- 
tion, 292 

Assistants  for  operation,  291 

Autoplastic  flaps,  367 

Autoplasty,   Bardenheuer's,  363 

BALLOON,  Bellocq's,  in  operation,  295 
Bardenheuer's  autoplasty  prosthesis, 
363 

method    for    unilateral    defect    of 

lower  jaw,  367 

Bellocq's  balloon  in  operation,  295 
Benign  lesions  following  trauma,  64 

tumors,  140 
Boennecken's  metal  splint,  360,  362 

wire  bridge,  357,  359 
Bone  prosthesis,  367 

CANNULA,  tampon,  in  operation,  295 
Carcinoma,  240 

adamantine  epithelioma  and,  differ- 
entiation, 187 

age  and,  241,  243 

bulging  of  antral  wall  in,  252 

central,  of  lower  jaw,  origin,  245 
of  upper  jaw,  origin,  245 

course,  259 

cystic,  175.     See  also  Epithelioma 
adamantine 

diagnosis,  259,  284 

edema  of  eyelid  in,  256 


379 


380 


INDEX 


Carcinoma,  epulis  and,  relative  fre- 
quency at  different  decades,  241- 
244 

etiology,  247 
extension  anteriorly,  253 

toward  base  of  pyramid,  254 
upward,  254 
face  ulcer  and,  258 
frequency,  240 
gum  ulcers  and,  257 
inoperable,  case,  265 
lymphatic  involvement,  256 
metastatic,  246,  258 
mouth  ulcerations  in,  257 
nasal  hemorrhages  in,  256 

polypi  and,  249 

obstruction  of  tear-duct  in,  256 
of  accessory  sinuses,  250 
of  alveolar  margin,  248 
of  antrum,  250 

case,  241,  242,  253 
of  floor  of  mouth,  prosthesis,  case, 

373 

of  lower  jaw  at  symphysis,  case,  259 
Boston    City   Hospital    cases, 

281 

case,  245,  261,  262,  266 
diagnosis,  284 
from  sarcoma,  with  lymphatic 

involvement,  case,  119 
inoperable  cases,  267 

duration  of  life,  270 
Massachusetts    General    Hos- 
pital cases,  272-281 
metastases  in,  258 
operated  on,  cases,  272 

death  from,  cases,  273 
operation,  259 

patients  alive,  277 
origin,  245 
prosthesis,  case,  372 
recurrence,  death  from,  cases, 

274 

remains  of,  263 

of  mucous  membrane,  epulis  and, 
differentiation,  36 


Carcinoma  of  nasal  fossse,  250 
of  orbit,  250 
of  palate,  323 

removal,  324 

of  upper   jaw,    Boston   City    Hos- 
pital cases,  281 
case,  241,  242,  248,  252,  254, 

256,  282 
diagnosis,  284 
inoperable  cases,  267 

duration  of  life,  270 
Massachusetts    General    Hos- 
pital cases,  264-272 
metastases  in,  258 
operated  on,  cases,  266,  270 
operation,  259,  288 

statistics,  283 
origin,  245 

summary  of  cases,  263 
time  of  death  after  treatment, 

264 

ulcerating,  case,  255,  257 
of  uvula,  323 
operation  for,  259,  288.     See  also 

Operation 
origin,  244,  250 
pain  in,  251 
plugging  of  nares,  254 
prognosis,  282 
recurrences,  260 

time  of,  282 

sarcoma  and,  differentiation,  81 
relative  frequency,  43 

at  different  decades,  241-244 
sex  and,  241,  243 
symptoms,  250,  251 
treatment,  259 
results,  260 

time  of  death  after,  264 
vision  and,  254 

Caries,  epulis  and,  differentiation,  35 
Carotid,  common,  compression  of,  294 
temporary,  293,  294 

ligation  of,  292.  294 
external,  compression  of,  293,  294 
ligation  of,  293,  294 


INDEX 


381 


Carotid,  external,  ligation  of,  cerebral 
embolism  after,  130 

internal,  ligation  of,  293 

ligation,  brain  symptoms,  292 
historic,  291 
in  operation,  291 
Cauterization  of  epulis,  37,  38 
Cell-rests  of  teeth,  172 
Celluloid  for  plastic  repair,  366 
Cementoma,  234 

Central  sarcoma,  44.     See  also  Sar- 
coma, central 
Cerebral    compression    in    leontiasis 

ossea,  339 
relief  from,  342 

embolism  after  ligation  of  external 

carotid,  130 
Chibret's     work     with     adamantine 

epithelioma,  195 
Chloroma  of  jaw,  24,  25 
Chondroma,  146 

age  and,  147 

benign,  146 

calcification,  148 

classification,  146 

craniofacial,  case,  149 

glandular,  of  palate,  325 

malignant,  147 

of  lower  jaw,  starting-point,  147 

of  orbit,  recurrent,  case,  149 

of  upper  jaw,  case,  150 
starting-point,  147 

operation  for,  recurrence,  150 

origin,  146 

rate  of  growth,  148 

starting-point,  147 

symptoms,  150 

treatment,  151 
Chondrosarcoma,  48,  51 
Common    carotid,    ligation    of,    292. 

See  also  Carotid,  common 
Compression  of  carotid  in  operation, 

293,  294 
Cord,    epithelial,    development,    165, 

166 
( 'niniofacial  enchondroma,  case,  149 


Crile's  nasopharyngeal  tubage  anes- 
thesia, 290,  295 
Cuspid,  development,  169 

section  of,  176 
Cylindroma  of  palate,  325 
Cystadenoma  of  jaw,  175.     See  also 

Epithelioma,  adamantine 
papillary,  from  tooth-follicle,  case, 

215 
Cysts,  197 

bibliography,  239 
dental,  223 
case,  224 
diagnosis,  224 
rate  of  growth,  224 
sarcoma  and,  differentiation,  80 
section,  225 
situation,  224 
size  of,  223 
treatment,  225 
dentigerous,  197 

adamantine  epithelioma  and,  184, 

219 

differentiation,  184,  185 
epithelioma    with,    184,    186, 

188,  189 
age  and,  198 
contents,  211 
diagnosis,  218,  284 
etiology,  203 
heterotopic,  198 
lining  membrane,  212 
Malassez's  theory,  207 
multilocular,  175,  214.     See  also 

Epithelioma,  adamantine 
of  lower  jaw,  197 

case,  200,  201,  202,  203,  204, 

208,  209,  213,  222,  223 
diagnosis,  284 
of  upper  jaw,  197,  201 
case,  198,  199 
diagnosis,  284 
pathology,  210 
position  of  tooth  in,  207 
rate  of  growth,  199 
situation  of,  202 


382 


INDEX 


Cysts,  dentigerous,  tooth  in,  211,  212 
toothless.  212 
tooth-like  masses  in,  219 
treatment,  220 
walls  of,  211 

epulis  and,  differentiation,  35,  36 

follicular,     197.     See    also    Cysts, 
dentigerous 

periosteal,  197,  226.     See  also  Root- 
cysts 

root-,    197,    226.     See    also    Root- 
cysts 

DENTAL  abscess,  epulis  and,  differen- 
tiation, 35 

cysts,  223.     See  also  Cysts,  dental 
Dentigerous    cysts,     197.     See    also 

Cysts,  dentigerous 
Dermoids,  212 

of  palate,  319 

removal,  324 
Diagnosis,  284 

age  in,  285 

character  of  tumor  in,  287 

duration  of  growth  in,  285 

history  in,  284 

jaw  involved  in,  286 

rate  of  growth  in,  285 

sex  in,  285 

situation  of  growth  in,  285 

trauma  in,  287 


EMBOLISM,  cerebral,  after  ligation  of 
external  carotid,  130 

from  ligation  of  carotid,  293 
Embryo,  lower  jaw  of,  164 
Empyema  of  antrum,   sarcoma  and, 

74,  78 
Enamel  organ,  development,  166,  167 

hood  of,  169 

Enchondroma.     See  Chondroma 
Endothelioma  of  palate,  325 
Enlarged  glands  of  neck,  80,  81 
Enucleation  of  eye  in  sarcoma,  114 


Epithelial  .cord,    development,    165; 

166 
odontoma,   175.     See  also  Epithe- 

lioma,  adamantine 
rests  of  teeth,  172 
Epithelioma,  adamantine,  173 
age  and,  176 
carcinoma    and,    differentiation, 

187 

characteristics,  184 
Chibret's  work,  195 
clinical  course,  175 
dentigerous  cyst  and,  184,  219 

differentiation,  184,  185 
dentigerous  cyst  with,  186,  188, 

189 

diagnosis,  184,  284 
epulis    and,    differentiation,    36, 

185 

Hildebrand's  case,  195 
Krause's  description,  193 

of    microscopic    pathology. 

193 

lymphatics  in,  181 
mucous  membrane  of,  181 
of  lower  jaw,  case,  177,  178,  179, 

180,  182 

diagnosis,  284 

of  upper  jaw,  178,  185 

diagnosis,  284 
origin,  173 
pathology,  gross,  187 

microscopic,  191 
prognosis,  196 
rate  of  growth,  180 
recurrences,  196 
relation  to  jaw,  180 
rupture  into  mouth,  184 
sarcoma  and,  differentiation,  187 
sex  and,  177 
situation,  177 
size.  180 
synonyms,  175 
treatment,  195 
of  palate,  323,  325 
removal,  324 


INDEX 


383 


Epulis,  17 

actinomycosis  and,  differentiation* 
35 

adamantine  epithelioma  and,  differ- 
entiation, 36,  185 

age  and,  242.  243 
of  occurrence,  18 

alveolar   abscess   and,    differentia- 
tion and,  35 

beginning  period,  24,  25 

carcinoma  and,  relative  frequency 
at  different  decades,  241-244 

carcinoma    of    mucous    membrane 
and,  differentiation,  36 

caries  and,  differentiation,  35 

causes,  local,  18 

cauterization,  37,  38 

consistence  of,  32 

course,  33 

cyst  and,  differentiation,  35,  36 

definition,  17 

dental  abscess  and,  differentiation, 
35 

diagnosis,  35,  284 

epithelioma  and,  differentiation,  36 

established  period,  24,  27 

excision,  37 

extraction  of  tooth  in,  37,  38 

fibrous,  20 

consistence  of,  32 
diagnosis,  37 
large  size,  30-32 
prognosis,  34 
treatment,  37 

fungosity  of  gums  and,  35 

giant-cell  sarcomatous,  21 
diagnosis,  37 
prognosis,  34 
treatment,  37 

granulomata  and,  differentiation,  35 

gum-boil  and,  30 
differentiation,  35 

in  pregnancy,  24 

large  size  of,  30-32 

liability  of  two  jaws,  18 

lymphatic  involvement,  35 


Epulis,  malignancy  of,  17,  19,  20,  35 
metastases  in,  38,  39 
neuralgia  and,  differentiation,  35 
odontoma  and,  differentiation,  35, 

36 

of  upper  jaw,  30 
oozing  of  blood  from,  32 
operation  for,  38 
palpation,  32 

papillary  growths  and,  differentia- 
tion, 35 

periods  in  growth,  24 
periostitis  and,  differentiation,  35 
prognosis,  34 

pushing  out  of  teeth  by,  19,  25 
recurrence  after  operation,  37,  38, 

39 

retained  wisdom  teeth  and,  differ- 
entiation, 36 
sarcoma  and,  relative  frequency  at 

different  decades,  241-244 
differentiation,  36 
of  upper  jaw  and,  71 
sex  frequency,  18 
silver  nitrate  in,  37 
site  of,  19,  28,  30 
stages  of,  24 
summary,  39 
symptoms,  24 
treatment,  37 

safest,  38 

ulceration  period,  24,  33 
varieties  of,  20 
well-defined  period,  24,  27 
Etherization,    nasopharyngeal,    290, 

295 

Excision  for  leontiasis  ossea,  342 
of  lower  jaw,  incision  for,  300 

prosthesis  for,  360 
of  one-half  lower  jaw,  305 

dividing  jaw  bone,  311 
incision  for,  308 
inspection,  312 
position  of  patient,  306 
prosthesis  for,  356,  358 
case,  374 


384 


INDEX 


Excision  of  upper  jaw,  295 
after-treatment,  301 
appearances  after,   299 
cleaning  sinuses  after,  298,  299 
dissection  of  neck,  301 
division  of  bony  attachments, 

297 

Ferguson- Webber  incision,  296 
incision  for,  296,  297,  300 
inspection  after,  298 
position  for,  295 
prosthesis  for,  360,  368 
removal  of  orbital  plate,  301 
technic,  295 
two  stages,  302 
Exhaustion  after  sarcoma  operation, 

91 

Exostosis,  hard  odontoma  and,  differ- 
entiation, 237 
osteoma,  156 
External  carotid,  ligation  of,  cerebral 

embolism  after,  130 
Eye  in  sarcoma  of  upper  jaw,  71,  72 

removal  of,  in  sarcoma,  114 
Eyelid,  edema  of,  in  carcinoma,  256 


FIBROMA,  140 
age  and,  141 
central,  141,  142 
diagnosis,  145,  284 
etiology,  143 
histology,  140 
of  lower  jaw,  142 

case,  141 

diagnosis,  284 
of  upper  jaw,  case,  140,  142 

diagnosis,  284 
origin,  140 
periosteal,  141 
symptoms,  144 
treatment,  145 
varieties,  141 
Fibrosarcoma,  51 

of  upper  jaw,  prosthesis  after  re- 
section, case,  134 


Fibrous  epulis,  20.     See  also  Epulis, 

fibrous 
Follicle,  tooth,  development,  168 

sections,  171,  173 
Follicular  cysts,  197.     See  also  Cysts, 

dentigerous 

Fritzsche's  tin  splint,  360,  365 
Fungosity  of  gums,  epulis  and,  35 


GIAXT-CELL  sarcoma.     See  Sarcoma, 

giant-cell 
sarcomatous  epulis,  21.     See  also 

Epulis,  giant-cell  sarcomatous 
Granulomata,  epulis  and,  differentia- 
tion, 35 
root,  35 
Gum-boil,  epulis  and,  30 

differentiation,  35 

Gummata,  sarcoma  and,  differentia- 
tion, 81 

trauma  and,  64 

Gums,  fungosity  of,  epulis  and,  35 
ulcers  of,  carcinoma  and,  257 


HAHL'S    apparatus    for    excision    of 

upper  jaw,  368,  369,  370 
Hair,  bulbous  ends  of,  163,  164 

development  of,  similarity  of  tooth 

development,  163,  165 
Hard    odontomata,    234.     See    also 
Odontoma,  hard 

palate,  leontiasis  ossea  of,  339 
sarcoma  of,  320 

rubber  prosthesis,  357 
Hematoma  from  trauma,  64 
Hemorrhage  after  sarcoma  operation, 
88 

in  operation,  291 
Hildebrand's     case     of     adamantine 

epithelioma,  195 
Hoffmann's  wire  prosthesis,  365 
Hood  of  enamel  organ,  169 
Hyperplasia  of  upper  jaw,  localized, 

158 


INDEX 


385 


INCISION  for  excision  of  lower  jaw,  300 
of  one  half  lower  jaw,  308 
of  upper  jaw,  296,  297,  300 

Ivory  splint  prosthesis,  369 


KOCHER'S   total    resection   of   upper 

jaw,  303 
Krause's  description  of  adamantine 

epithelioma,  193 
Kuhn's  oral  intubation  in  Kocher's 

operation,  305 


LABOR,   tumor  of  rectus    abdominis 

after,  64 

Leontiasis  ossea,  333 
anosmia  in,  347 
bone  thickening  in,  336 
case,  334,  335,  348 
cerebral  compression  in,  339 

relief  from,  342 
course,  341 
ear  symptoms,  340 
etiology,  333 
eye  symptoms,  339,  340,  343,  344, 

345,  351 
relief  from.  345 
nasal  fossae  in,  339,  347 
neuralgia  in,  339,  348 
of  palate,  339 
of  upper  jaw,  336,  338 
orbit  in,  339,  340,  343,  344,  345, 

351 

pathology,  334 
prognosis,  341 
symptoms,  339 
tear-duct  in,  347 
treatment,  342 

Ligation  of  carotid  in  operation,  291 
of   external    carotid,    cerebral   em- 
bolism after,  130 
Lipoma,  152 

25 


Lower  jaw  of  embryo,  164 
Lymphangiosarcoma,  case,  69 

of  lower  jaw,  cystic,  case,  126 
Lymphatics,  carcinomatous  involve- 
ment in  sarcoma,  case,  119 
in  adamantine  epithelioma,  181 
in  carcinoma,  256 
in  mixed  palatal  tumors,  329 
involvement  of,  in  epulis,  35 
removal  of,  in  sarcoma,  138 


MARTIN'S  permanent  prosthesis,  366 

Melanosarcoma,  65 

of  upper  jaw  starting  in  palate,  322 

Meningitis,  purulent,  after  sarcoma 
operation,  87 

Metal  splint,  Boennecken's,  360,  362 

Mixed  sarcoma,   48.     See  also  Sar- 
coma, mixed 

Morphin  before  anesthetic,  289 

Mosetig-Moorhof's  plumbum  of  wax 
for  root-cysts,  234 

Mouth    cleansing    before    operation, 
288 

Myositis  from  trauma,  64 

Myxoma,  151 

Myxosarcoma,  51,  151 


NASAL     cavities,     cleansing     before 

operation,  288 
fossae,  carcinoma  of,  250 

in  leontiasis  ossea,  339,  347 
polyp,  sarcoma  and,  70,  78 

carcinoma  and,  249 
sinuses,  anatomy,  313 

relation  to  upper  jaw,  313 
Nasopharyngeal    tubage,    anesthesia 

by,  290,  295 
Neck,  dissection  of,  301 

glands,  enlarged,  case,  80,  81 
Neuralgia,  epulis  and,  differentiation, 

35 

in  leontiasis  ossea,  339,  348 
infra-orbital,  sarcoma  and,  71 


386 


INDEX 


Neuralgia,  sarcoma  of  upper  jaw  and, 

68 

Nitrate  of  silver  in  epulis,  37 
Nose,   plugging  of,  in  carcinoma  of 

jaw,  254 


ODONTOMA,  162 
bibliography,  196 
classifications,  162 
composite,  223 
compound,  223 
definition,  162 
diagnosis,  284 
epithelial,    175.     See   also   Epilhe- 

lioma,  adamantine 
epulis  and,  differentiation,  35,  36 
follicular,     197.     See    also    Cysts,  ; 

dentigerous 
hard,  234 

case,  236,  237 

diagnosis,  234 

exostosis  and,  differentiation,  237 

of  lower  jaw,  pathology,  235 

osteomyelitis     and,     differentia- 
tion, 237 

of  lower  jaw,  diagnosis,  284 
of  upper  jaw,  diagnosis,  284 
sarcoma  and,  differentiation,  80 
varieties,  163 
Operation,  288 
anesthesia,  290 
assistants  for,  291 
Bellocq's  balloon  in,  295 
carotid  ligation  in,  291.     See  also 

Carotid 
cleansing  mouth,  288 

nasal  cavities,  288 
compression  of  carotid  in,  293,  294 
dissection  of  neck,  301 
excision,  295.     See  also  Excision 
hemorrhage  in,  291 
Kocher's,  303 
morphin  before,  289 
on  upper  jaw,  288 
pharyngeal  tamponade  in,  295 


Operation,  pneumonia  after,  292 

position  of  patient,  290 

preliminary  steps,  288 

principles  of,  302 

Rose  position  in,  292,  295 

stomach-tube  in,  289 

tracheotomy  in,  291 

Trendelenburg's    tampon    cannula 

in,  295 
Oral  intubation  in  Kocher's  operation, 

305 
Orbit,  carcinoma  of,  250 

in  leontiasis  ossea,  339,  340,  343, 
344,  345,  351 

osteoma  of,  153,  154,  160 
Orbital  plate,  removal  of,  301 

in  sarcoma,  114 
Osteochondroma  of  upper  jaw,  case, 

151 
Osteochondromyxosarcoma,  case,  92 

removal  of  jaw  and  formation  of 

new  hard  palate,  92 
Osteofibrochondroma,  case,  146 
Osteofibroma  of  lower  jaw,  case,  155 
Osteoma,  152 

exostosis,  156 

of  alveolar  process,  158 

of  antrum  of  Highmore,  156 

of  lower  jaw,  160 
case,  155,  157 

of  orbit,  160 
case,  154 
inner  side,  case,  153 

of  sinuses,  160 

of  upper  jaw,  156 
case,  153 

origin,  152 

sarcoma  and,  differentiation,  81 

structure,  156 
Osteomyelitis  after  trauma,  64 

hard    odontoma    and,    differentia- 
tion, 237 
Osteoplastic  flap,  367 

total  resection  of  upper  jaw,  303 
Osteosarcoma,  49,  51 

case,  74 


INDEX 


387 


Osteosarcoma  of  lower  jaw,  118 
case,  127 
periosteal,  case,  65,  123,  124 


PALATE,  adenoma  of,  325 
carcinoma  of,  323 

removal,  324 
cylindroma  of,  325 
dermoids  of,  319 

removal,  324 

enchondroma  of,  glandular,  325 
endothelioma  of,  325 
epithelioma  of,  323,  325 

removal,  324 
leontiasis  ossea  of,  339 
papilloma  of,  319 

removal,  324 
perithelioma  of,  325 
sarcoma  of,  320 
case,  321 
melanotic,  322 
plexiform,  325 
removal,  324 
tumors,  319 
mixed,  325 

at  Massachusetts  General  Hos- 
pital, 330 
case,  327 

characteristics,  328 
clinical  pictures,  328 
lymphatics  in,  329 
malignancy,  329 
origin,  326-328 
pathology,  325 
recurrences,  329 
situation,  328 
synonyms,  325 
removal,  324 

Papilla,  development,  167 
epulis  and,  differentiation,  35 
of  palate,  319 

removal,  324 

Paradental  epithelial  debris,  172 
Paraffin  filling  for  root-cysts,  233 
Parotid,  sarcoma  of.  79,  82 


Partsch  operation  for  root-cyst,  232 

prosthesis  apparatus,  362,  364 
Periosteal  cysts,  197,  226.     See  also 

Root-cysts 
sarcoma,  44,  45.     See  also  Sarcoma, 

periosteal 

Periosteum,   alveolo-dental,    171 
Periostitis,  alveolar,  sarcoma  and,  dif- 
ferentiation, 79 
epulis  and,  differentiation,  35 
ossifying,  after  trauma,  64 
Perithelioma  of  palate,  325 
Permanent  teeth,  derivation,  165 
Pharyngeal  tamponade  in  operation, 

295 

Plastic  repair,  363 
Plexiform  sarcoma  of  palate,  325 
Plumbum  of  wax  for  root-cysts,  234 
Pneumonia  after  operation,  292 

after  sarcoma  operation,  90 
Polyp,  nasal,  carcinoma  and,  249 

sarcoma  and,  70,  78 
Position  of  patient  for  operation,  290 
Pregnancy,  epulis  in,  24 
Prosthesis,  354 

after  total  operation  for  fibrosar- 

coma  of  upper  jaw,  case,  134 
aims  of,  355 
aluminum  bronze  plate,  362 

wire,  359 

Bardenheuer's  autoplastic,  363 
Boennecken's  metal  splint,  360,  362 
bone,  367 

cases,  371,  372,  373,  374 
celluloid  for,  366 
conclusions,  373 
for  excision,  360 

of  one-half  lower  jaw,  case,  356, 

358,  374 

of  upper  jaw,  368 
for  replacing  symphysis,  356,  358, 

359 

for  symphysis  resection,  373,  374 
Fritzsche's  tin  splint,  360,  365 
general  considerations,  354 
Hahl's  apparatus,  368,  369,  370 


388 


INDEX 


Prosthesis,  hard-rubber,  357 

immediate,  354 

for    exarticulation    of    one-half 
lower  jaw,  356,  358,  374 

ivory  splint,  369 

Martin-Oilier,  357 

methods,  359 

Partsch's  apparatus,  362,  364 

permanent,  Martin's,  366 

Sauer  slanting  splint,  360 

Sauer-von  Tropmann,  357 

secondary,  354 

wire,  365 
Pulp  of  teeth,  169 


RECTUS  abdominis,  tumor  of,   after 

labor,  64 

Resection  of  jaw,  transplantation  of 
rib  after,  368 

of  one-half  lower  jaw,  prosthesis  for, 
360 

of  upper  jaw,  Kocher's,  303 
Rib,  transplantation  of,  after  jaw  re- 
section, 368 
Rodent  ulcer,  case,  255 
Root  granulomata,  35 

of  teeth,  171 

longitudinal  section,  175 
Root-cysts,  197,  226 

contents,  227 

development,  229 

diagnosis,  232 

Mosetig-Moorhof's     plumbum     of 
wax  for,  234 

of  lower  jaw,  case,  227 

of  upper  jaw,  case,  226 

origin,  227 

paraffin  filling  for,  233 

Partsch  operation  for,  232 

pathology,  228 

plumbum  of  wax  for,  234 

situation,  226 

symptoms,  230 

treatment,  232 

Witzel's  paraffin  filling  for,  233 


Rose  position  in  operation,  292,  295 
Round-cell    sarcoma,    52.     See    also 
Sarcoma,  round-cell 


SAC  of  tooth,  development,  168 
Sarcoma,  40 

adamantine  epithelioma  and,  differ- 
entiation, 187 
age  and,  41,  242,  243 
carcinoma  and,  relative  frequency, 

43 

at  different  decades,  241-244 
central,  44 

and  periosteal,  differentiation,  46 
diagnosis,  284 

epulis  and,  differentiation,  36 
relative   frequency    at    different 

decades,  241-244 

etiologic  importance  of  trauma,  58 
etiology,  58 
facts  regarding,  40 
frequency  of  jaw  affected,  43 
giant-cell,  44 

of  lower  jaw,  to  left  of  symphy- 

sis,  case,  55 
of  symphysis  of  lower  jaw  after 

trauma,  case,  60 
histologic  groups,  41 
Massachusetts  General  Hospital 

cases,  58 

material  studied,  43 
melanotic,  of  palate,  322 
mixed,  48 

recurrence  after  operation,  51 
of  lower  jaw,  55,  77,  115 

case,   66,   76,    116,    12o,    127, 

247 

diagnosis,  284 

duration  before  operation,  124 
facts  regarding,  40 
followed  by  carcinoma  and  in- 
vasion of  lymphatics,  case, 
119 

giant-cell,  case,  128 
treatment,  136 


INDEX 


389 


Sarcoma  of  lower  jaw,  inoperable,  139 

cases.  129 

lymphatic  removal,  138 
malignancy,  116 
Massachusetts    General    Hos- 
pital cases,  results,  122 
melanotic,  case,  128 
near  angle,  case,  67 
operation  for,  136 

duration  before,  124 

mortality,  117 

partial,  results,  115 

partial  vs.  total,  136 

recurrences,  139 

results,  115,  118 

total,  results,  115 

total  vs.  partial,  136 
periosteal,  treatment,  137 
prosthesis,  case,  371 
rate  of  growth,  116 
round-cell,     inoperable     case. 
129,  130 

treatment,  137 
site,  53 
spindle-cell,  120 

case,  125,  127 

treatment,  137 
statistics     of     Massachusetts 

General  Hospital,  109 
treatment,  136,  138 
varieties,  115 
of  palate.  320 
case,  321 
melanotic,  322 
plexiform.  325 
removal,  324 
of  parotid,  79,  82 
of  upper  jaw,  67 

beginning   period,    symptoms, 

67 
carcinoma  and,  differentiation, 

81 

cheek  symptoms,  68,  72 
clinical  pictures,  67 
cures,  98 
cysts  and,  differentiation,  80 


Sarcoma  of  upper  jaw,  diagnosis,  78, 

284 

dissection  of  neck  in,  111 
edema  of  eye  in,  106 
empyema  of  antrum  and,  74, 

78 

epulis  and,  71 
extension  to  nose,  orbit,  cheek, 

and  temporal  region,  107 
eye  in,  71,  72 
facts  regarding.  40 
general  health,  72 
giant-cell,  case,  84 

treatment,  137 
glandular  enlargement  in,  72 
gummata  and,  differentiation, 

81 

in  antrum,  treatment,  138 
infra-orbital  neuralgia  and,  71 
inoperable,  99,  100,  139 

case,  112 
ligation  of  external  carotid  in; 

cerebral  embolism  from.  130- 

134 

lymphatic  removal,  138 
Massachusetts    General    Hos- 
pital case:?.  103 
mixed,  92 

nasal  polyp  and,  70,  78 
neuralgia  and,  68,  71 
odontomata   and,    differentia- 
tion, 80 
operation  for,  136,  288 

causes  of  death  after,  87 

cures,  98 

dissection  of  neck  in,  111 

early  vs.  late,  98 

exhaustion  after,  91 

hemorrhage  after,  88 

in  every  case,  107 

late  vs.  early,  98 

mortality,  83 
abroad,  86 

partial,  cases,  95 

recurrences,  100,  102 
results,  105,  106,  115 


390 


INDEX 


Sarcoma  of  upper  jaw,  operation  for, 
partial  vs.  total,  94,  136 

pneumonia  after,  90 

prolongation  of  life  by,  106 

purulent    meningitis    after, 
87 

recurrences,  113,  139 

removal  of  eye,  114 
of  orbital  plate,  114 

repeated,  case,  88 

results,  104,  115 

selection  of  cases,  108 

sepsis  after,  87 

shock  after,  91 

total,  recurrences,  102,  108 
results,  104,  115 

total  vs.  partial,  94,  136 
osteomata  and,  differentiation, 

81 
periosteal,  case,  74 

treatment,  137 
periostitis  and,  differentiation, 

79 

prognosis,  82 
recurrence,  98,  113 
recurrent,  case,  117 
removal  of  eye,  114 

of  orbital  plate,  114 
round-cell,  case,  96,  97,  112 

ligation  of  external  carotid 
in,  130-134 

partial    operation    for,    fu- 
tility, 95,  96 

treatment,  137 
jaw,  site,  53 

spindle-cell,  case,  88,  89,  90 

treatment,  137 
statistics     of     Massachusetts 

General  Hospital,  109 
summary  of  clinical    pictures, 

73 
symptoms,  67 

established  period,  71 

late  period,  72 
syphilis  and,  82 
teeth  in,  68 


Sarcoma  of  jaw,  total  resection  for, 

99 

treatment,  136 
tumor  of,  72 

tumors  of  soft  parts  and,  differ- 
entiation, 80 

operation  for,  288.     See  also  Opera- 
tion 

origin,  40 

part  of  jaw  first  attacked,  53 
periosteal,  44,  45 

and  central,  differentiation,  46 
case,  74 

rate  of  growth,  41 
round-cell,  52 
sex  and,  43,  54 

starting  from  antrum,  gaining  ac- 
cess to,  97 
trauma  and,  58 
treatment,  136 
Sauer  slanting  splint,  360 
Sepsis  after  sarcoma  operation,  87 
Shock  after  sarcoma  operation,  91 
Silver  nitrate  in  epulis,  37 
Sinuses,  nasal,  anatomy,  313 

relation  to  upper  jaw,  313 
osteoma  of,  160 
Skin-muscle-periosteum-bone  flaps, 

369 

Slanting  splint  of  Sauer,  360 
Spindle-cell    sarcoma.     See   Sarcoma 

oi  upper  jaw,  spindle-cell 
Splint,  ivory,  for  prosthesis,  369 
metal,  of  Boennecken,  360,  362 
slanting,  of  Sauer,  360 
tin,  of  Fritzsche,  360,  365 
Stellate  reticulum  of  teeth,  169 
Stomach-tube  before  operation,  289 
Stratum  intermedium  of  teeth,  170 
Suture    material    for   plastic   repair, 

363 
Symphysis,    removal    of,    prosthesis 

after,  356,  358,  359 
resection  of,  in  sarcoma,  61,  63 

prosthesis,  373,  374 
Syphilis,  sarcoma  and,  82 


INDEX 


391 


TEAR-DUCT  in  1'eontiasis  ossea,  347 
obstruction  of,  in  carcinoma,  256 
Teeth,  ameloblastic  layer  of,  169 
development,  162,  163 

similarity  to  hair  development, 

163,  165 
enamel,  development,  166,  167 

hood  of,  169 
epithelial  rests  of,  172 
expulsion  of,  by  epulis,  19,  25 
follicles,  development,  168 

sections,  171,  173 
in  dentigerous  cysts,  211,  212 
in  sarcoma  of  upper  jaw,  68 
jaw  and,  170 

papilla  of,  development,  167 
permanent,  derivation,  165 
pulp  of,  169 
roots  of,  171 

longitudinal  section,  175 
sac  of,  development,  168 
section,  166 
sockets  of,  170 
stellate  reticulum  of,  169 
stratum  intermedium  of,  170 
wisdom,  retained,  epulis  and,  differ- 
entiation, 36 

Tin  splint,  Fritzsche's,  360,  365 
Tooth-socket,  170 
Total  resection  of  upper  jaw,   osteo- 

plastic,  303 

Tracheotomy  in  operation  on  jaws, 
291 


Trauma,  benign  lesions  following,  64 

gumma  and,.  64 

hematoma  from,  64 

in  diagnosis,  287 

myositis  from,  64 

ossifying  peritonitis  after,  64 

osteomyelitis  after,  64 

sarcoma  and,  58 
Treatment,  operative,  288.     See  also 

Operation 
Trendelenburg's  tampon  cannula  in 

operation,  295 
Tumor    of    rectus     abdominis    after 

labor,  64 


ULCER,  rodent,  case,  255 
Ulceration  of  epulis,  24,  33 
Ulcers  of  face,  carcinoma  and,  258 

of  gums,  carcinoma  and,  257 
Uvula,  carcinoma  of,  323 


VISION,  carcinoma  and,  254 


WIRE  as  suture  material  for  plastic 

repair,  363 
Wisdom  teeth,  retained,  epulis  and, 

differentiation,  36 
Witzel's  paraffin  filling  for  root-cysts, 

233 


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Diirck  and  Hektoen's 

General  Pathologic  Histology 

Atlas  and   Epitome  of   General  Pathologic  Histology.      By   PR. 

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PATHOLOGY. 


Stengel's 
Text-Book  of  Pathology 


The    New  (5th)  Edition 


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PERSONAL  AND   PRESS  OPINIONS 


William  H.  Welch,  M.  D.. 

Professor  of  Pathology,  Johns  Hopkins  University,  Baltimore,  Md. 

"  I  consider  the  work  abreast  of  modern  pathology,  and  useful  to  both  students  and  practi- 
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special  pathologic  anatomy,  with  more  than  usual  emphasis  upon  pathologic  physiology. 

Ludvig  Hektoen,  M.  D.. 

Professor  of  Pathology,  Rush  Medical  College,  Chicago. 

"  I  regard  it  as  the  most  serviceable  text-book  for  students  on  this  subject  yet  written  by  an 
American  author." 

The  Lancet,  London 

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sible and  more  especially  from  the  point  of  view  of  the  'clinical  pathologist/ 
have  been  faithfully  carried  out,  and  a  valuable  text-book  is  the  result.     We  can  most  favo 
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The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
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Pharmacy,  Chemistry,  and  kindred  branches;  with  over  100  new  and 
elaborate  tables  and  many  handsome  illustrations.  By  W.  A.  NEWMAN 
BORLAND,  M.  D.,  Editor  of  "  The  American  Pocket  Medical  Diction- 
ary." Large  octavo,  nearly  880  pages,  bound  in  full  flexible  leather. 
Price,  $4.50  net;  with  thumb  index,  $5.00  net. 

A  KEY  TO   MEDICAL   LITERATURE— WITH   2000   NEW  TERMS 

Borland's   Dictionary  defines  hundreds  of  the  newest  terms  not  defined  in  any 

other  dictionary — bar  none.      These  new  terms   are   live,    active  words,    taken 

right  from  modern  medical  literature. 

It    gives    the    pronunciation    of   all    words.       Many    dictionaries    give    only    the 

accent. 

It   makes  a   feature   of  the    derivation   or    etymology    of  the    words.      In    some 

dictionaries  the  etymology  occupies  only  a  secondary  place,  in  many  cases  no 

derivation  being  given  at  all.      In   "  Borland,"   practically  every  word  is  given 

its  derivation. 

In   "  Borland "   every  word  has  a  separate  paragraph,   thus  making  it  easy  to 

find  a  word  quickly. 

The  tables  of  arteries,   muscles,    nerves,    veins    etc.,    are    of  the   greatest   help 

in  assembling  anatomic  facts.      In  them  are  classified  for  quick  study  all  the 

necessary  information  about  the  various  structures. 

In    "  Borland"    every   word    is    given    its    definition — a    definition    that    defines 

in  the  fewest  possible  words.      In  some  dictionaries  hundreds  of  words  are  not 

defined  at  all,  referring  the  reader  to  some  other  source  for  the  information  he 

wants  at  once. 

Howard  A.  Kelly,   M.  D.,  Johns  Hopkins   University,  Baltimore 

"Dr.  Dorland's  dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
size.  Xo  errors  have  been  found  in  ray  use  of  it." 

J.  Collins  Warren,  M.  D.,  LL.D.,  F.R.C.S.  (Hon.),  Harvard  Medical  School 

"  I  regard  it  as  a  valuable  aid  to  my  medical  literary  work.  It  is  very  complete  and  of 
convenient  size  to  handle  comfortably.  I  use  it  in  preference  to  any  other." 


PATHOLOGY. 


Stengel's 
Text-Book  of  Pathology 


The    New  (sth)   Edition 


A  Text-Book  of  Pathology.  By  ALFRED  STENGEL,  M.  D.,  Professor 
of  Clinical  Medicine  in  the  University  of  Pennsylvania.  Octavo  volume 
of  979  pages,  with  400  text-illustrations,  many  in  colors,  and  7  full-page 
colored  plates.  Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  $6.50  net. 

WITH  400  TEXT-CUTS.  MANY  IN  COLORS.  AND  7  COLORED  PLATES 

In  this  work  the  practical  application  of  pathologic  facts  to  clinical  medicine 
is  considered  more  fully  than  is  customary  in  works  on  pathology.  While  the 
subject  of  pathology  is  treated  in  the  broadest  way  consistent  with  the  size  of  the 
book,  an  effort  has  been  made  tc  present  the  subject  from  the  point  of  view  of  the 
clinician.  In  the  second  part  of  the  work  the  pathology  of  individual  organs  and 
tissues  is  treated  systematically  and  quite  fully  under  subheadings  that  clearly 
indicate  the  subject-matter  to  be  found  on  each  page.  In  this  edition  the  section 
dealing  with  General  Pathology  has  been  most  extensively  revised,  several  of  the 
important  chapters  having  been  practically  rewritten.  A  very  useful  addition 
is  an  Appendix  treating  of  th  technic  of  pathologic  methods,  giving  briefly  the 
most  important  methods  at  present  in  use  for  the  study  of  pathology,  including, 
however,  only  those  methods  capable  of  giving  satisfactory  results.  The  book 
will  be  found  to  maintain  fully  its  popularity. 


PERSONAL  AND  PRESS  OPINIONS 


William  H.  Welch,  M.  D.. 

Professor  of  Pathology,  Johns  Hopkins  University,  Baltimore,  Md. 

"  I  consider  the  work  abreast  of  modern  pathology,  and  useful  to  both  students  and  practi- 
tioners. It  presents  in  a  concise  and  well-considered' form  the  essential  facts  of  general  and 
special  pathologic  anatomy,  with  more  than  usual  emphasis  upon  pathologic  physiology." 

Ludvig   Hektoen,  M.  D.. 

Professor  of  Pathology,  Rush  Medical  College,  Chicago. 

"  I  regard  it  as  the  most  serviceable  text-book  for  students  on  this  subject  yet  written  by  an 
American  author." 

The  Lancet.  London 

"This  volume  is  intended  to  present  the  subject  of  pathology  in  as  practical  a  form  as  pos- 
sible and  more  especially  from  the  point  of  view  of  the  'clinical  pathologist/ 
have  been  faithfully  carried  out,  and  a  valuable  text-book  is  the  result.     We  can  most  favorably 
recommend  it  to  our  readers  as  a  thoroughly  practical  work  on  clinical  pathology. 


SAUNDERS'    BOOKS   ON 


Mallory  and  Wright's 
Pathologic  Technique 

Fourth  Edition,  Revised  and  Enlarged 


Pathologic  Technique.  A  Practical  Manual  for  Workers  in  Patho- 
logic Histology,  including  Directions  for  the  Performance  of  Autopsies 
and  for  Clinical  Diagnosis  by  Laboratory  Methods.  By  FRANK  B. 
MALLORY,  M.  D.,  Associate  Professor  of  Pathology,  Harvard  Univer- 
sity;  and  JAMES  H.  WRIGHT,  M.  D.,  Director  of  the  Pathologic  Labora- 
tory, Massachusetts  General  Hospital.  Octavo  of  480  pages,  with  152 
illustrations.  Cloth,  $3.00  net. 

WITH  CHAPTERS  ON  POST-MORTEM  TECHNIQUE  AND  AUTOPSIES 

In  revising  the  book  for  the  new  edition  the  authors  have  kept  in  view  the 
needs  of  the  laboratory  worker,  whether  student,  practitioner,  or  pathologist,  for 
a  practical  manual  of  histologic  and  bacteriologic  methods  in  the  study  of  patho- 
logic material.  Many  parts  have  been  rewritten,  many  new  methods  have  been 
added,  and  the  number  of  illustrations  has  been  considerably  increased.  Among 
tne  new  matter  may  be  mentioned,  as  of  particular  interest,  Zinsser's  anae'robu 
method  for  plate  cultures;  the  ox-bile  method,  the  medium  of  Endo,  and  tho 
malachite-green  medium  for  typhoid  bacillus;  Wright's  method  for  blood-platelets 
and  bone-marrow  giant  cells;  Best's  improved  stain  for  glycogen;  von  Kossa's 
silver  method  for  lime-salts;  Levaditi's  method  of  staining  the  spirochaeta  pal- 
lida;  and  Sir  A.  E.  Wright's  bacterial  vaccines.  The  paragraphs  on  the  micro- 
organism of  actinomycosis  have  been  rewritten.  The  work  continues  to  be  a 
most  useful  laboratory  and  post-mortem  guide,  full  of  practical  information. 


PERSONAL  AND  PRESS  OPINIONS 


Wm.  H.  Welch,  M.  D., 

Professor  of  Pathology,  Johns  Hopkins  University,  Baltimore. 

"  I  have  been  looking  forward  to  the  publication  of  this  book,  and  I  am  glad  to  say  that  I 
find  it  a  most  useful  laboratory  and  post-mortem  guide,  full  of  practical  information  and  well 
up  to  date." 

Boston  Medical  and  Surgical  Journal 

"  This  manual,  since  its  first  appearance,  has  been  recognized  as  the  standard  guide  in  patho- 
logical technique,  and  has  become  well-nigh  indispensable  to  the  laboratory  worker." 

journal  of  the  American  Medical  Association 

"  One  of  the  most  complete  works  on  the  subject,  and  one  which  should  be  in  the  library 
•)f  every  physician  who  hopes  to  keep  pace  with  the  great  advances  made  in  pathology." 


EMBRYOLOGY, 


Heisler's 
Text-Book  qf  Embryology 


The    New  (3d)   Edition 


A  Text-Book  of  Embryology.  By  JOHN  C.  HEISLER,  M.D.,  Pro- 
fessor of  Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia. 
Octavo  volume  of  435  pages,  with  212  illustrations,  32  of  them  in 
colors.  Cloth,  $3.00  net. 

WITH    212     ILLUSTRATIONS,     32     IN     COLORS 

The  fact  of  embryology  having  acquired  in  recent  years  such  great  interest 
in  connection  with  the  teaching  and  with  the  proper  comprehension  of  human 
anatomy,  it  is  of  first  importance  to  the  student  of  medicine  that  a  concise  and 
yet  sufficiently  full  text-book  upon  the  subject  be  available.  This  new  edition 
represents  all  the  latest  advances  recently  made  in  the  science  of  embryology. 
Many  portions  have  been  entirely  rewritten,  and  a  great  deal  of  new  and  impor- 
tant matter  added.  A  number  of  new  illustrations  have  also  been  introduced  and 
these  will  prove  very  valuable.  The  previous  editions  of  this  work  filled  a  gap 
most  admirably,  and  this  new  edition  will  undoubtedly  maintain  the  reputation 
already  won.  Heisler's  Embryology  has  become  a  standard  work. 


PERSONAL  AND   PRESS  OPINIONS 


G.  Carl  Huber,  M.  D., 

Professor  of  Histology  and  Embryology,  University  of  Michigan,  Ann  Arbor. 
"  I  find  the  second  edition  of  '  A  Text-Book  of  Embryology'  by  Dr.  Heisler  an  improve 
ment  on  the  first.     The  figures  added  increase  greatly  the  value  of  the  work.     I  am  again 
recommending  it  to  our  students." 

William  Wathen.  M.  D., 

Professor  of  Obstetrics,  Abdominal  Surgery,  and  Gynecology,  and  Dean,  Kentucky  School  of 

Medicine,  Louisville,  Ky. 

"  It  is  systematic,  scientific,  full  of  simplicity,  and  just  such  a  work  as  a  medical  student 
will  be  able  to  comprehend." 

Birmingham  Medical  Review,  England 

"  We  can  most  confidently  recommend  Dr.  Heisler's  book  to  the  student  of  biology  or 
medicine  for  his  careful  study,  if  his  aim  be  to  acquire  a  sound  and  practical  acquaintance  with 
the  subject  of  embryology." 


SAUNDERS'    BOOKS   ON 


Wells'  Chemical  Pathology 


Chemical  Pathology. — Being  a  Discussion  of  General  Pathology 
from  the  Standpoint  of  the  Chemical  Processes  Involved.  By  H. 
GIDEON  WELLS,  PH.  D.,  M.  D.,  Assistant  Professor  of  Pathology  in  the 
University  of  Chicago.  Octavo  of  549  pages.  Cloth,  $3.25  net. 

A  PRACTICAL   BOOK 

Dr.  Wells'  work  is  written  for  the  physician,  for  those  engaged  in  research  in 
pathology  and  physiologic  chemistry,  and  for  the  medical  student.  In  the  intro- 
ductory chapter  are  discussed  the  chemistry  and  physics  of  the  animal  cell,  giving 
the  essential  facts  of  ionization,  diffusion,  osmotic  pressure,  etc.,  and  the  relation 
of  these  facts  to  cellular  activities.  Special  chapters  are  devoted  to  Diabetes  and 
to  Uric-acid  Metabolism  and  Gout. 

Wm.   H.  Welch,   M.  D. 

Professor  of  Pathology,  Johns  Hopkins  University. 

"The  work  fills  a  real  need  in  the  English  literature  of  a  very  important  subject,  and  I 
shall  be  glad  to  recommend  it  to  my  students." 

Lusk's 
Elements  of  Nutrition 

Elements  of  the  Science  of  Nutrition.  By  GRAHAM  LUSK,  PH.  D., 
Professor  of  Physiology  at  Cornell  Medical  School.  Octavo  volume 
of  302  pages.  Cloth,  $3.0x3  net. 

THE   NEW   (2d)    EDITION 

Prof.  Lusk  presents  the  scientific  foundations  upon  which  rests  our  knowledge 
of  nutrition  and  metabolism,  both  in  health  and  in  disease.  There  are  special 
chapters  on  the  metabolism  of  diabetes  and  fever,  and  on  purin  metabolism. 
The  work  will  also  prove  valuable  to  students  of  animal  dietetics  at  agricultural 
stations. 

Lewellys  F.  Barker.  M.  D. 

Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  University. 
"  I  shall  recommend  it  highly  to  my  students.     It  is  a  comfort  to  have  such  a  discussion 
of  the  subject  in  English." 


HISTOLOGY. 


Bohm,  Davidoff,  anc 
Huber's  Histology 


A  Text-Book  of  Human  Histology.  Including  Microscopic  Tech- 
nic.  By  DR.  A.  A.  BOHM  and  DR.  M.  VON  DAVIDOFF,  of  Munich,  and 
G.  GARL  HUBER,  M.  D.,  Professor  of  Histology  and  Embryology  in 
the  University  of  Michigan,  Ann  Arbor.  Handsome  octavo  of  528 
pages,  with  361  beautiful  original  illustrations.  Flexible  cloth,  $3.50  net. 

THE    NEW   (2d)    EDITION,    ENLARGED 

The  work  of  Drs.  Bohm  and  Davidoff  is  well  known  in  the  German  edition, 
and  has  been  considered  one  of  the  most  practically  useful  books  on  the  subject 
of  Human  Histology.  This  second  edition  has  been  in  great  part  rewritten  and 
very  much  enlarged  by  Dr.  Huber,  who  has  also  added  over  one  hundred  origi- 
nal illustrations.  Dr.  Huber's  extensive  additions  have  rendered  the  work  the 
most  complete  students'  text-book  on  Histology  in  existence. 

Boston  Medical  and  Surgical  Journal 

"  Is  unquestionably  a  text-book  of  the  first  rank,  having  been  carefully  written  by  thorough 
masters  of  the  subject,  and  in  certain  directions  it  is  much  superior  to  any  other  histological 
manual." 


DrewV 
Invertebrate  Zoology 

A  Laboratory  Manual  of  Invertebrate  Zoology.  By  OILMAN  A. 
DREW,  PH.!).,  Professor  of  Biology  at  the  University  of  Maine.  With  the 
aid  of  Members  of  the  Zoological  Staff  of  Instructors  of  the  Marine  Biolog- 
ical Laboratory,  Woods  Holl,  Mass.  iamo  of  200  pages.  Cloth,  $1.25  net. 

A    LABORATORY    WORK 

The  subject  is  presented  in  a  logical  way,  and  the  type  method  of  study  has 
been  followed,  as  this  method  has  been  the  prevailing  one  for  many  years. 

Prof.  Allison  A.  Smyth,  Jr.,  Virginia  Polytechnic  Institute 

"  I  think  it  is  the  best  laboratory  manual  of  zoology  I  have  yet  seen.  The  large  number 
of  forms  dealt  with  makes  the  work  applicable  to  almost  any  locality." 


12  SAUNDERS'    BOOKS   ON 

American 
Text-Book  of  Pathology 


American  Text-Book  of  Pathology.  Edited  by  LUDVIG  HEKTOEN, 
M.  D.,  Professor  of  Pathology,  Rush  Medical  College,  in  affiliation  with 
the  University  of  Chicago ;  and  DAVID  RIESMAN,  M.  D.,  Professor  of 
Clinical  Medicine,  Philadelphia  Polyclinic.  Handsome  imperial  octavo, 
1245  pages,  443  illustrations,  66  in  colors.  Cloth,  $7.50  net;  Sheep  or 
Half  Morocco,  $9.00  net. 

MOST  SUMPTUOUSLY  ILLUSTRATED   PATHOLOGY  IN   ENGLISH 

The  present  work  is  the  most  representative  treatise  on  the  subject  that  has 
appeared  in  English.  It  furnishes  practitioners  and  students  with  a  comprehensive 
text-book  on  the  essential  principles  and  facts  in  General  Pathology  and  Pathologic 
Anatomy,  with  especial  emphasis  on  the  relations  of  the  latter  to  practical  medicine. 
The  illustrations  are  nearly  all  original,  and  those  in  color  are  printed  directly  in 
the  text.  In  fact,  the  pictorial  feature  of  the  work  forms  a  complete  atlas  of  patho- 
logic anatomy  and  histology. 

Quarterly  Medical  Journal,  Sheffield,  England 

"As  to  the  illustrations,  we  can  only  say  that  whilst  all  of  them  are  good,  most  of  them 
are  really  beautiful,  and  for  them  alone  the  book  is  worth  having.  Both  colored  and  plain, 
they  are  distributed  so  profusely  as  to  add  very  largely  to  the  interest  of  the  reader  and  to 
help  the  student. 


McConnell's  Pathology 


A  Manual  of  Pathology.  By  GUTHRIE  McCoNNELL,  M.  D.,  Path- 
ologist to  the  Skin  and  Cancer  Hospital,  St.  Louis.  I2mo  of  523 
pages,  with  170  illustrations.  Flexible  leather,  $2.50  net. 

Dr.  McConnell  has  discussed  his  subject  with  a  clearness  and  precision  of 
style  that  render  the  work  of  great  assistance  to  both  student  and  practitioner. 
The  illustrations  have  been  introduced  for  their  practical  value. 

New  York  State  Journal  of   Medicine 

"  The  book  treats  the  subject  of  pathology  with  a  thoroughness  lacking  in  many  works  of 
greater  pretension.  The  illustrations — many  of  them  original — are  profuse  and  of  exceptional 
excellence." 


HISTOLOGY.  I3 


Diirck  am)  Hektoen's 

Special    Pathologic    Histology 

Atlas  and  Epitome  of  Special  Pathologic  Histology.     By  DR.  H. 

DURCK,  of  Munich.  Edited,  with  additions,  by  LUDVIG  HEKTOEN,  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  two  parts. 
Part  I. — Circulatory,  Respiratory,  and  Gastro-intestinal  Tracts.  120 
colored  figures  on  62  plates,  and  158  pages  of  text.  Part  II. — Liver, 
Urinary  and  Sexual  Organs,  Nervous  System,  Skin,  Muscles,  and 
Bones.  123  colored  figures  on  60  plates,  and  192  pages  of  text.  Per 
part :  Cloth,  $3.00  net.  In  Saunders1  Hand- Atlas  Series. 

The  great  value  of  these  plates  is  that  they  represent  in  the  exact  colors  the  effect 
of  the  stains,  which  is  of  such  great  importance  for  the  differentiation  of  tissue. 
The  text  portion  of  the  book  is  admirable,  and,  while  brief,  it  is  entirely  satisfac- 
tory in  that  the  leading  facts  are  stated,  and  so  stated  that  the  reader  feels  he  has 
grasped  the  subject  extensively. 

William  H.  Welch,  M.  D., 

Professor  of  Pathology,  Johns  Hopkins  University,  Baltimore. 

"I  consider  Diirck's  'Atlas  of  Special  Pathologic  Histology,'  edited  by  Hektoen,  a  very 
useful  book  for  students  and  others.  The  plates  are  admirable." 

Sobotta  and  Huber's 
Human  Histology 

Atlas  and  Epitome  of  Human  Histology.  By  PRIVATDOCENT  DR. 
J.  SOBOTTA,  of  Wiirzburg.  Edited,  with  additions,  by  G.  CARL  HUBER, 
M.  D.,  Professor  of  Histology  and  Embryology  in  the  University  of 
Michigan,  Ann  Arbor.  With  214  colored  figures  on  80  plates,  68 
text-illustrations,  and  248  pages  of  text.  Cloth,  $4.50  net.  In 
Saunders'  Hand- Atlas  Series. 

INCLUDING   MICROSCOPIC  ANATOMY 

The  work  combines  an  abundance  of  well-chosen  and  most  accurate  illustra- 
tions, with  a  concise  text,  and  in  such  a  manner  as  to  make  it  both  atlas  and  text- 
book'. The  great  majority  of  the  illustrations  were  made  from  sections  prepared 
from  human  tissues,  and  always  from  fresh  and  in  every  respect  normal  specimens. 
The  colored  lithographic  plates  have  been  produced  with  the  aid  of  over  thirty  colors. 

Boston  Medical  and  Surgical  Journal 

"  In  color  and  proportion  they  are  characterized  by  gratifying  accuracy  and  lithographic 
beauty." 


I4  SAUNDERS  BOOKS   ON 

Levy  arid  Klemperer's 
Clinical  Bacteriology 

The  Elements  of  Clinical  Bacteriology.  By  DRS.  ERNST  LEVY  and 
FELIX  KLEMPEREK,  of  the  University  of  Strasburg.  Translated  and 
edited  by  AUGUSTUS  A.  ESHNER,  M.  D.,  Professor  of  Clinical  Medicine, 
Philadelphia  Polyclinic.  Octavo  volume  of  440  pages,  fully  illustrated. 
Cloth,  $2.50  net. 

S.  Solis-Cohen,  M.  D., 

Professor  of  Clinical  Afedicine,  Jefferson  Medical  College,  Philadelphia. 

"  I  consider  it  an  excellent  book.     I  have  recommended  it  in  speaking  to  my  students." 

Lehmann,  Neumann,  arid 
Weaver's  Bacteriology 

Atlas  and  Epitome  of  Bacteriology :  INCLUDING  A  TEXT-BOOK  OF 
SPECIAL  BACTERIOLOGIC  DIAGNOSIS.  By  PROF.  DR.  K.  B.  LEHMANN 
and  DR.  R.  O.  NEUMANN,  of  Wurzburg.  From  the  Second  Revised  and 
Enlarged  German  Edition.  Edited,  with  additions,  by  G.  H.  WEAVER, 
M.  D.,  Assistant  Professor  of  Pathology  and  Bacteriology,  Rush  Medical 
College,  Chicago.  In  two  parts.  Part  I. — 632  colored  figures  on  69 
lithographic  plates.  Part  II. — 511  pages  of  text,  illustrated.  Per  part: 
Cloth,  $2.50  net.  In  Saimders"  Hand-Atlas  Scries. 

Lewis'  Anatomy  and  Physi- 
ology for  Nurses 

Anatomy  and  Physiology  for  Nurses.  By  LfiRov  LEWIS,  M.  D., 
Surgeon  to  and  Lecturer  on  Anatomy  and  Physiology  for  Nurses  at 
the  Lewis  Hospital,  Bay  City,  Michigan.  I2mo  of  375  pages,  with 
150  illustrations.  Cloth,  $1.75  net. 

THE  NEW  (2d)  EDITION 

Nurses  Journal  of  the  Pacific  Coast 

"  It  is  not  in  any  sense  rudimentary,  but  comprehensive  in  its  treatment  of  the  subjects  in 
hand." 


PATHOLOGY,    BACTERIOLOGY,    AND   PATHOLOGY.  15 

Eyre's    Bacteriologic   Technique 

THE  ELEMENTS  OF  BACTERIOLOGIC  TECHNIQUE.  A  Laboratory 
Guide  for  the  Medical,  Dental,  and  Technical  Student.  By  J.  W. 
H.  EYRE,  M.  D.,  F.  R.  S.  Edin.,  Lecturer  on  Bacteriology  at  the 
Medical  and  Dental  Schools,  London.  Octavo  of  375  pages,  with 
170  illustrations.  Cloth,  $2.50  net. 

American  Text-Book  of  Physiology  second  Edition 

AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  In  two  volumes.  Edited  by 
WILLIAM  H.  HOWELL,  PH.  D.,  M.D.,  Professor  of  Physiology  in  the  Johns 
Hopkins  University,  Baltimore,  Md.  Two  royal  octavos  of  about  600 
pages  each,  illustrated.  Per  volume:  Cloth,  $3.00  net;  Half  Morocco, 
$4.25  net. 

' '  The  work  will  stand  as  a  work  of  reference  on  physiology.  To  him  who  desires  to  know 
the  status  of  modern  physiology,  who  expects  to  obtain  suggestions  as  to  further  physio- 
logic inquiry,  we  know  of  none  in  English  which  so  eminently  meets  such  a  demand." — 
The  Medical  News. 

Warren's  Pathology  and  Therapeutics        second  Edition 

SURGICAL  PATHOLOGY  AND  THERAPEUTICS.  By  JOHN  COLLINS  WARREN, 
M.  D.,  LL.D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Med- 
ical School.  Octavo,  873  pages,  136  relief  and  lithographic  illustrations, 
33  in  colors.  With  an  Appendix  on  Scientific  Aids  to  Surgical  Diagnosis 
and  a  series  of  articles  on  Regional  Bacteriology.  Cloth,  $5.00  net; 
Half  Morocco,  $6.50  net. 

Gorham's  Bacteriology 

A  LABORATORY  COURSE  IN  BACTERIOLOGY.  For  the  Use  of  Medical, 
Agricultural,  and  Industrial  Students.  By  FREDERIC  P.  GORHAM,  A.  M., 
Associate  Professor  of  Biology  in  Brown  University,  Providence,  R.  I., 
etc.  i2mo  of  192  pages,  with  97  illustrations.  Cloth,  $1.25  net. 

"  One  of  the  best  students'  laboratory  guides  to  the  study  of  bacteriology  on  the  mar- 
ket. .  .  .  The  technic  is  thoroughly  modern  and  amply  sufficient  for  all  practical  pur- 
poses."— American  Journal  of  the  Medical  Sciences. 

Raymond's  Physiology  New  (3d)  ^^ 

HUMAN  PHYSIOLOGY.  By  JOSEPH  H.  RAYMOND,  A.  M.,  M.  D.,  Pro- 
fessor of  Physiology  and  Hygiene,  Long  Island  College  Hospital,  New 
York.  Octavo  of  685  pages,  with  444  illustrations.  Cloth,  $3.50  net. 

"  The  book  is  well  gotten  up  and  well  printed,  and  may  be  regarded  as  a  trustworthy 
guide  for  the  student  and  a  useful  work  of  reference  for  the  genera:  practitioner.  The 
illustrations  are  numerous  and  are  well  executed." — The  Lancet,  London. 


16  BACTERIOLOGY,    PHYSIOLOGY,    AND   HISTOLOGY. 

Ball's    Bacteriology  Sixth  Edition,  Reviied 

ESSENTIALS  OF  BACTERIOLOGY  :  being  a  concise  and  systematic  intro- 
duction to  the  Study  of  Micro-organisms.     By  M.  V.  BALL,  M.  D.,  Late 
Bacteriologist  to  St.  Agnes'  Hospital,  Philadelphia,     ramo  of  289  pages, 
with  135  illustrations,  some  in  colors.     Cloth,  $1.00  net.     In  Saunders 
Question-  Compend  Series. 

"  The  technic  with  regard  to  media,  staining,  mounting,  and  the  like  is  culled  from  the 
latest  authoritative  works." — The  Medical  Times,  New  York. 

Budgett's  Physiology  New  od)  Edition 

ESSENTIALS  OF  PHYSIOLOGY.  Prepared  especially  for  Students  of  Medi- 
cine, and  arranged  with  questions  following  each  chapter.  By  SIDNEY 
P.  BUDGETT,  M.  D.,  formerly  Professor  of  Physiology,  Washington  Uni- 
versity, St.  Louis.  Revised  by  HAVAN  EMERSON,  M.  D.,  Demonstratoi 
of  Physiology,  Columbia  University.  i2mo  volume  of  250  pages,  illus 
trated.  Cloth,  $1.00  net.  Saunders1 Question-  Compend  Series. 

"He  has  an  excellent  conception  of  his  subject.  .  .  It  is  one  of  the  most  satisfactory 
books  of  this  class" — University  of  Pennsylvania  Medical  Bulletin. 

Leroy's  Histology  New  (4th)  Edition 

ESSENTIALS  OF  HISTOLOGY.  By  Louis  LEROY,  M.  D.,  Professor  oi 
Histology  and  Pathology,  Vanderbilt  University,  Nashville,  Tennessee. 
izmo,  263  pages,  with  92  original  illustrations.  Cloth,  $1.00  net.  In 
Saunders'  Question-  Compend  Series. 

"  The  work  in  its  present  form  stands  as  a  model  of  what  a  student's  aid  should  be  ;  and 
we  unhesitatingly  say  that  the  practitioner  as  well  would  find  a  glance  through  the  book 
of  lasting  benefit." — The  Medical  World,  Philadelphia. 

Barton  and  Wells'  Medical  Thesaurus 

A  THESAURUS  OF  MEDICAL  WORDS  AND  PHRASES.  By  WILFRED  M. 
BARTON,  M.  D.,  Assistant  Professor  of  Materia  Medica  and  Therapeutics, 
and  WALTER  A.  WELLS,  M.  D. ,  Demonstrator  of  Laryngology,  Georgetown 
University,  Washington,  D.  C.  i2mo,  534  pages.  Flexible  leather, 
$2.50  net;  thumb  indexed,  $3.00  net. 

American  Pocket  Dictionary  sixth Edi<;- 

BORLAND'S  POCKET  MEDICAL  DICTIONARY.  Edited  by  W.  A.  NEW- 
MAN BORLAND,  M.  B.,  Editor  "American  Illustrated  Medical  Dic- 
tionary." Containing  the  pronunciation  and  definition  of  the  principal 
words  used  in  medicine  and  kindred  sciences,  with  64  extensive  tables. 
598  pages.  Flexible  leather,  with  gold  edges,  $1.00  net;  with  patent 
thumb  index,  $1.25  net. 

"I  can  recommend  it  to  our  students  without  reserve." — J.  H.  HOLLAND,  M.  D.,  of 
the  Jefferson  Medical  College,  Philadelphia. 


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